Every finding on record at Oconto Health and Rehab Center

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 sampled resident was free of a significant medication error. R1 was prescribed clindamycin (an antibiotic) for facial cellulitis following a hospital visit on 12/15/25. R1 missed five doses of the antibiotic when it was not available from the pharmacy. The facility did not update the physician about the missed doses. R1's wound worsened and R1 requested to be transferred to the hospital again on 12/17/25. R1's wound was irrigated, debrided, and packed. R1 received intravenous (IV) antibiotics and was discharged with wound care orders and oral antibiotics. Findings include: The facility's Medication Administration policy, revised November 2024, indicates: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. On 3/24/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including cellulitis of the left cheek. R1's Minimum Data Set (MDS) assessment, dated 1/2/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions. A progress note, dated 12/15/25 at 7:58 PM, indicated R1 had a swollen area that was approximately 4 to 5 centimeters (cm) in diameter on the left upper cheek that was hard, red, warm to the touch, and painful. R1 stated R1 had the area for at least 3 days and it kept getting bigger, warmer, and more painful. The note indicated the writer worked on another wing the day before (12/14/25) but saw the area and noted it was more noticeable, larger in size, and appeared worse on 12/15/25. The area contained a 0.25 cm area in the center that appeared open but was not draining. R1 tried warm compresses and salve on 12/14/25 but they did not help. R1 stated R1 could not sleep last night because R1's continuous positive airway pressure (CPAP) mask sits on top of the sore and it hurts to wear the mask. R1 was concerned the area was infected and contemplated going to the emergency room (ER) for evaluation. The writer checked the facility's medical record system and did not see any requests to the physician for advisement. R1 stated R1 would let the writer know if the area became more painful to determine if the writer should notify the on-call physician. A progress note, dated 12/15/25 at 9:15 PM, indicated R1 requested to be sent to the ER for treatment. The writer contacted Emergency Medical Services (EMS) for transport. A progress note, dated 12/15/25 at 10:50 PM, indicated R1 returned from the hospital. R1 was treated with clindamycin for facial cellulitis and had the following order: Clindamycin HCL oral capsule 300 milligrams (mg) give 1 capsule by mouth three times daily for facility cellulitis related to cutaneous abscess of face (start date 12/16/25). R1's Medication Administration Record (MAR) indicated due to medication unavailability, three doses of clindamycin were not administered ton 12/16/25 and two doses were not administered on 12/17/25. The PM dose was administered on 12/17/25. R1's medical record indicated the cellulitis became more painful and R1 requested to be transported to the hospital on [DATE] at 11:33 PM. A hospital Discharge summary, dated [DATE] to 12/18/25, indicated R1 had a possible abscess within the soft tissues of the left cheek that measured 1.5 cm x 1.7 cm. The area did not appear amenable to drainage in the ER. Imaging was consistent with preseptal cellulitis (a common infection of the eyelid skin and soft tissues anterior to the orbital septum), not orbital cellulitis (a serious sight- and life-threatening infection of the soft tissues behind the eye socket). R1 was administered clindamycin and instructed to follow-up with R1's physician in 1 to 7 days. R1's medical record indicated the cellulitis became more painful on 12/20/25 and R1 requested to go to the hospital again. A hospital Discharge summary, dated [DATE] to 12/26/25, indicated R1 was admitted to the hospital with a 1 cm x 1.4 cm methicillin-resistant Staphylococcus (MRSA) left cheek abscess with preseptal cellulitis. Irrigation and debridement were completed on 12/20/25. R1 was admitted to the hospital and treated with IV vancomycin through 12/23/25. On 12/24/25, the wound was irrigated with 10 milliliters (ml) of saline, debrided, and packed with non-iodinated ribbon gauze. The wound was covered with a 2 x 2 gauze and secured with paper tape. R1 was discharged on 12/26/25 with an order to continue cleansing and packing the wound twice daily until healed. R1 also had an order for TMP/Sulfa Double Strength (DS) (an antibiotic) twice daily for 7 to 14 days until healed. On 3/24/26 at 2:47 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility did not have clindamycin in contingency and the pharmacy was unable to deliver it timely. DON-B called the pharmacy numerous times to expedite the delivery; however, clindamycin was not delivered until the 12/17/25 PM shift. DON-B indicated the facility added clindamycin to their contingency stock to prevent it from happening in the future. DON-B verified R1 missed a total of five doses of clindamycin from 12/16/25 to 12/17/25.

Based on staff interview and record review, the facility did not report allegations of abuse and exploitation to the State Agency (SA) for 1 resident (R) (R4) of 1 sampled resident.R4 informed staff on 2/6/26 that Certified Nursing Assistant (CNA)-C stated R4 could not get out of bed for a limited amount of time. R4 also reported that CNA-C accepted a gift from R4. The allegations of abuse and exploitation were not reported to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/1/25, indicates: It is the guideline of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.From 3/24/26 to 3/25/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression. R4's Minimum Data Set (MDS) assessment, dated 2/14/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R4 had intact cognition.Surveyor reviewed the facility's grievance file and noted R4 filed a grievance with the facility on 2/6/26. The grievance indicated R4 asked if staff could transfer R4 into R4's wheelchair but was told R4 could not get up if R4 only wanted to be up for an hour. The grievance was reviewed by Director of Nursing (DON)-B. The summary of findings indicated R4 requested to get up but changed R4's mind due to the duration of time R4 would have to be in the wheelchair.On 3/24/26 at 12:32 PM, Surveyor interviewed DON-B who verified R4 reported to staff on 2/6/26 that CNA-C refused to get R4 into R4's wheelchair during an overnight shift if R4 only wanted be up for an hour. DON-B spoke with CNA-C who indicated CNA-C told R4 CNA-C would assist R4 into the wheelchair, however, CNA-C might be unable to get R4 out of the wheelchair in an hour if CNA-C was assisting other residents. CNA-C indicated CNA-C would assist R4 as soon as possible. R4 chose not to transfer into the wheelchair at that time. On 3/25/26 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B regarding reporting allegations of abuse to the SA. NHA-A and DON-B confirmed allegations of abuse should be reported to the SA.2. A progress note, dated 2/11/26 by Social Worker Designee (SWD)-D, indicated R4 spoke with attorneys who advised R4 to share with the facility that R4 gave CNA-C a tumbler as a gift. The note indicated R4 knew R4 was not supposed to give gifts to staff but wanted to do something nice for CNA-C.On 3/24/26 at 12:32 PM, Surveyor interviewed DON-B who indicated R4 informed DON-B on 2/6/26 that R4 purchased a mug for CNA-C who refused to accept the mug on multiple occasions but finally accepted it due to pressure from R4. On 3/25/26 at 1:00 PM, Surveyor interviewed NHA-A and DON-B regarding reporting allegations of exploitation to the SA. NHA-A and DON-B confirmed allegations of exploitation should be reported to the SA.

Based on staff interview and record review, the facility did not thoroughly investigate allegations of abuse and exploitation for 1 resident (R) (R4) of 1 sampled resident.R4 informed staff on 2/6/26 that Certified Nursing Assistant (CNA)-C stated R4 could not get out of bed for a limited amount of time. R4 also reported that CNA-C accepted a gift from R4. The allegations of abuse and exploitation were not thoroughly investigated. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/1/25, indicates: It is the guideline of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.From 3/24/26 to 3/25/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression. R4's Minimum Data Set (MDS) assessment, dated 2/14/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R4 had intact cognition.1. Surveyor reviewed the facility's grievance file and noted R4 filed a grievance with the facility on 2/6/26. The grievance indicated R4 asked staff to transfer R4 into R4's wheelchair but was told R4 could not get up if R4 only wanted to be up for an hour. The grievance was reviewed by Director of Nursing (DON)-B. The summary of findings indicated R4 requested to get up but changed R4's mind due to duration of time R4 had to be in the wheelchair. The summary of actions indicated staff were educated on residents' rights to choose when they want to be up and out of bed. The grievance did not indicate other residents and staff were interviewed to determine if other residents had similar experiences. In addition, CNA-C was not removed from resident care pending the outcome of the investigation.On 3/24/26 at 12:32 PM, Surveyor interviewed DON-B who verified R4 reported on 2/6/26 that CNA-C refused to transfer R4 into R4's wheelchair during an overnight shift if R4 only wanted to be up for an hour. DON-B indicated CNA-C told R4 that CNA-C would assist R4 into the wheelchair, however, CNA-C might be unable to get R4 out of the wheelchair in exactly an hour if CNA-C was assisting other residents. CNA-C indicated CNA-C would assist R4 as soon as possible. R4 chose not to transfer into the wheelchair at that time. On 3/25/26 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who indicated allegations of abuse should be reported to the State Agency (SA) and thoroughly investigated. NHA-A and DON-B agreed a more thorough investigation could have been completed.2. A progress note, written by Social Worker Designee (SWD)-D and dated 2/11/26, indicated R4 spoke with attorneys who advised R4 to tell the facility R4 gave CNA-C a tumbler as a gift. R4 knew R4 was not supposed to give gifts to staff but wanted to do something nice for CNA-C.On 3/24/26 at 12:32 PM, Surveyor interviewed DON-B who verified R4 informed DON-B on 2/6/26 that R4 purchased a mug for CNA-C which CNA-C refused to accept on multiple occasions but ultimately accepted due to pressure from R4. DON-B stated DON-B spoke to CNA-C who returned the mug. DON-B provided proof that all staff were educated on customer service and not to accept gifts from residents. The facility did not provide evidence that other residents and staff were interviewed to determine if other gifts were given and accepted. On 3/25/26 at 1:00 PM, Surveyor interviewed NHA-A and DON-B regarding thoroughly investigating the allegation of exploitation. NHA-A and DON-B agreed a more thorough investigation could have been completed.

Based on observation, staff and resident interview, and record review, the facility did not ensure continuous positive airway ressure (CPAP) machines were cleaned for 3 residents (R) (R1, R2, and R3) of 3 sampled residents. R1, R2, and R3 used a CPAP machines for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Staff did not clean the CPAP machines per medical orders and facility policy. Findings include: The facility's CPAP/BiPAP Cleaning policy, revised 6/11/25 indicates: It is the expectation of this facility to clean CPAP/bilevel positive airway pressure (BiPAP) equipment in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and manufacturer's recommendations in order to prevent the occurrence or spread of infection .6. Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use . 1. On 3/24/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia and obstructive sleep apnea. R1's Minimum Data Set (MDS) assessment, dated 1/2/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions. Surveyor reviewed R1's average volume-assured pressure support (AVAP) orders and noted the following: ~ Clean AVAP mask daily, one time a day (start date 12/14/23) On 3/24/26 at 10:03 AM, Surveyor interviewed R1 who indicated lack of AVAP mask cleaning started the irritation on R1's face along along with staff popping a pimple. R1 was diagnosed with cellulitis of the face on 12/15/25. Surveyor reviewed R1's December 2025 Treatment Administration Record (TAR) which did not contain an order to clean the AVAP mask on 12/4/25. (See interview under example 3.) 2. On 3/24/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including obesity and obstructive sleep apnea. R2's MDS assessment, dated 3/2/26, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's healthcare decisions. Surveyor reviewed R2's CPAP orders and noted the following: ~ Clean CPAP mask, headgear, and tubing with mild soap and warm water. Rinse tubing thoroughly and hang to air dry. Do not use alcohol or bleach products on machines or mask each morning every Friday for sleep apnea care (start date 12/14/24) On 3/24/26 at 11:00 AM, Surveyor interviewed R2 who indicated R2's CPAP mask was washed once since admission. Surveyor reviewed R2's March 2026 TAR and noted CPAP cleaning was documented with a 4 on 3/6/26 and 3/16/26 which indicated a nursing progress note indicated why the treatment was not completed. R2's medical record did not contain nursing progress notes regarding CPAP cleaning. On 3/24/26 at 11:40 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R2's medical record did not contain progress notes for 3/6/26 and 3/16/26 to indicate why R2's CPAP was not cleaned. 3. On 3/24/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypoxia. R3's MDS assessment, dated 3/2/26, had a BIMS score of 14 out of 15 which indicated R3 had intact cognition. R3 had an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed R3's BiPAP orders and noted the following: ~ Clean BiPAP mask one time a day (start date 2/14/26) On 3/24/26 at 11:20 AM, Surveyor interviewed R3 who was unsure if staff cleaned R3's BiPAP mask daily. Surveyor reviewed R3's March 2026 TAR and noted BiPAP cleaning was not documented on 3/4/26. On 3/24/26 at 11:15 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated nurses are responsible for cleaning CPAP/BiPAP/AVAP masks and document the cleaning in the resident's TAR. On 3/24/26 at 2:47 PM, Surveyor interviewed DON-B who indicated CPAP/BIPAP/AVAP masks should be cleaned once daily with soap and water and the tubing should be cleaned once weekly. DON-B indicated staff are expected to document completion in the resident's TAR. DON-B verified the missing dates of completion for R1, R2, and R3.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible. This practice had the potential to affect more than 4 of the 40 residents residing in the facility.The facility's dryers contained lint that covered approximately three-quarters of the of the bottom of the lint trap and was approximately one inch high.Findings include:On 9/17/25, Nursing Home Administrator (NHA)-A confirmed the facility's dryers are Unimac Alliance laundry systems dryers.The Unimac Alliance Laundry Systems Dryer operator's manual indicates: 1. Inspect the area surrounding tumble dryers, remove all combustible materials, including lint, before operating the machines .3. Clean lint from lint compartment and screen to maintain proper airflow and avoid overheating .Before cleaning the lint screen, open tumble dryer door and allow cylinder to completely stop. a. Open the lint panel. b. Remove all accumulated lint in the lint compartment area. Lightly brush any lint that may be left on the lint screen. c. Be sure the lint screen is not torn. d. The lint screen is designed to completely cover the entire opening in the lint screen panel. Be sure that it does so. e. Wipe lint off of the cabinet high limit thermostat. f. Replace the lint compartment panel on the tumble dryer ensuring a tight fit and lock if applicable .Monthly: 1. Remove lint and debris from inside the exhaust duct to maintain proper airflow and avoid overheating. a. Remove external duct and duct access covers, if present. b. Clean inside of duct with a vacuum. c. Clean dampers and make sure they operate freely. d. Replace duct and all access covers before returning tumble dryer to operation. 2. Ensure even lint distribution over lint screen. 3. Carefully wipe any accumulated lint off the cabinet high limit thermostat and thermistor, including perforated cover. 4. Clean lint and debris buildup from blower to maintain proper operation.The facility's Policy and Procedure Lint Trap Cleaning indicates: 1. Lint trap to be checked and cleaned every three loads. 2. Remove all lint on the screens and any lint on the bottom or around the screen. 3. Maintenance will once a week take the vacuum and clean the small hard to reach areas and around any sensors. 4. Outside of machine gets wiped down weekly and as needed, keeping it clean and free of dust and dirt .On 9/15/25 at 9:50 AM, Surveyor toured the laundry room with NHA-A who indicated the facility's housekeeping/laundry lead staff was not working that day. When Surveyor asked NHA-A to remove the Dryer A lint trap, Surveyor noted the lint trap contained a large amount of lint. The bottom of the trap contained lint that was approximately one inch high and covered three-quarters of the bottom of the trap which extended the length and width of the dryer. Surveyor interviewed NHA-A who indicated laundry staff should clean lint traps once daily. NHA-A confirmed the amount of lint observed in the Dryer A lint trap and indicated the trap appeared to not have been cleaned daily. Surveyor then requested NHA-A remove the Dryer B lint trap. Surveyor and NHA-A observed the bottom of the lint trap that extended the length and width of the dryer and noted lint that was approximately one-half inch high and half the width of the lint trap. Surveyor and NHA-A reviewed a check-off sheet near the dryers that contained documentation indicating the dates and times the lint traps were cleaned. NHA-A confirmed the last documented date for lint trap cleaning was 4/7/25. NHA-A indicated NHA-A would provide additional lint trap cleaning documentation to Surveyor. Surveyor then observed a maintenance staff sweep out the Dryer A and B lint traps with a broom.On 9/16/25, NHA-A provided Surveyor with a lint trap cleaning documentation sheet. Surveyor noted the documentation indicated the lint traps were cleaned twice daily. NHA-A indicated the laundry lead keeps the sheet in another spot other than on the clipboard next to the dryer since staff move and lose the sheet.

Based on observation, staff and resident interview, and record review, the facility did not ensure a Continuous Positive Airway Pressure (CPAP) machine (which delivers a stream of oxygenated air to a person's airway) was used under a physician's order and cleaned appropriately for 1 resident (R) (R21) of 1 sampled resident.R21 used a CPAP machine. R21 did not have a physician's order to use the machine or orders to maintain and clean the machine. In addition, R21 did not have a diagnosis that supported use of the machine.Findings Include:The facility's admission Orders document, revised 5/1/25, indicates: A Physician, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist must provide written and/or verbal orders for residents' immediate care and needs .The written and/or verbal orders should include at a minimum: a. Dietary; b. Medication orders, if indicated; c. Routine care orders; .The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan.The facility's admission of a Resident policy and procedure, revised 5/1/25, indicates: The admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician .The admission process has several phases: .b. Once the resident/family has selected the facility, pre-admission information should be gathered. Preadmission information may include, but is not limited to: i. History and physical; ii. Discharge summary; iii. Physician's orders; iv. Medication and/or treatment records; v. Consultation notes; vi. Labs/diagnostic information; vii. Wound care notes; viii. Mental health evaluations; ix. Physician progress notes; x. Nursing notes; xi. Therapy evaluations/notes .2. Upon admission, the designated facility staff will obtain information and perform assessments per their respective departments and per facility protocol. Information gathered will be placed into the resident's medical record via the facility's means of recordkeeping .From 9/15/25 to 9/17/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] from a hospital. R21's Minimum Data Set (MDS) assessment, dated 9/10/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R21 had intact cognition. A document in R21's medical record from the discharging hospital, dated 9/3/25, indicated: Order: CPAP naps and at bedtime. Another document from the discharging hospital, dated 9/4/25, indicated: Hospital CPAP set up. Settings are 5-20 centimeters of water) cmH2O, large full-face mask, and room air.R21's hospital Discharge summary, dated [DATE], did not include orders for a CPAP machine.R21's baseline care plan dated 9/8/25, included a section titled Oxygen Use with Room Air (RA) with CPAP and Bilevel Positive Airway Pressure (BIPAP) listed. Only RA was circled which indicated at the time of admission the facility was not aware that R21 had a CPAP machine as part of R21's plan of care.A care plan, initiated 9/9/25, indicated R21 had altered respiratory status/difficulty breathing and indicated: BIPAP/CPAP/Variable Positive Airway Pressure (VPAP) Settings: Titrated pressure: (Specify) cmH2O via (Specify: nasal pillow, nose mask or full-face mask) (Specify frequency). (Of note: R21's care plan was not person-centered for R21 and did not indicate which machine R21 used. In addition, a nasal pillow, nose mask, or full-face mask and the frequency were not specified.On 9/15/25 at 9:27 AM, Surveyor observed R21 in bed wearing a face mask attached to a CPAP machine.On 9/15/25 at 10:15 AM, Surveyor interviewed R21 who verified R21 used a CPAP machine. R21 stated R21 used a gallon of distilled water provided by the facility (which was observed on R21's night stand) to fill the reservoir every night but did not have supplies to clean the mask, tubing, or machine like R21 had at home. R21 stated staff had not cleaned the mask, tubing, or machine either. R21 stated the CPAP machine worked and was set at 20 but was different than the machine R21 had at home. On 9/16/25 at 8:05 AM, Surveyor noted R21's medical record did not contain a diagnosis to support use of the CPAP machine. In addition, R21's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not contain orders or treatments related to use of the CPAP machine.On 9/16/25 at 1:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the facility's Oxygen Administration policy. NHA-A stated there should be orders in R21's TAR to wash and maintain the hose and mask and would verify that with Director of Nursing (DON)-B.On 9/16/25 at 1:43 PM, Surveyor interviewed DON-B who verified R21's hospital Discharge summary, dated [DATE], did not contain CPAP orders which is why R21's medical record did not include CPAP orders. DON-B stated the facility was informed of R21's pending admission through the hub (an offsite department that handles admissions corporate-wide) and that R21 would need a CPAP machine. The facility ordered a CPAP machine in preparation for R21's admission. When R21 was admitted approximately three days later, a CPAP machine was not listed on R21's hospital discharge summary. DON-B indicated CPAP orders were not entered, however, the CPAP machine was already set up in R21's room. DON-B stated the discharge summary and physician orders are where a CPAP machine and settings are identified if needed. DON-B stated the facility was working on obtaining orders and a diagnosis for R21's CPAP use along with orders to care for the equipment.On 9/16/25 at 2:32 PM, Surveyor reviewed R21's medical record which included the following orders and diagnosis: ~ Clean CPAP mask, tubing, and head gear with soap and water weekly one time a day every Wednesday related to obstructive sleep apnea (OSA) (Active: 9/17/25 at 7:00 AM, entered 9/16/25).~ Apply CPAP when sleeping. Settings are 5-20 cmH2O, large mask, room air, one time a day related to OSA and as needed for OSA (Active: 9/16/25 at 2:00 PM, entered 9/16/25).~ A new diagnosis of obstructive sleep apnea was entered on 9/16/25. On 9/16/25 at 2:44 PM, DON-B provided Surveyor with the two hospital documents (noted above) that were scanned into R21's medical record. DON-B stated R21's admission date was delayed a few days and the documents were not seen by staff upon R21's admission on [DATE].

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R38, R35, and R8) of 7 sampled residents received a pneumococcal vaccine as indicated.Upon admission to the facility, R38, R35, and R8 signed consent to receive a pneumococcal vaccine. The vaccines were not administered. In addition, a physician order to administer the vaccine was not obtained for R8. Findings include:The facility's General Immunization/Vaccination policy, revised 3/30/25, indicates: It is the guidelines of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases .7. Following assessment for potential medical contraindications, the specified vaccination(s) may be administered in accordance with physician-approved standing orders if such are used, or a practitioner order is obtained .12. In case of lack of availability of the specified vaccine, or other issues with the availability leading to an inability to implement a specified immunization program, the facility will demonstrate: a. The vaccine has been ordered and the facility received either the vaccine or a confirmation of the order indicating that the vaccine has been shipped or that the product is not available but will be shipped when the supply is available .1.On 9/16/25, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including fusion of spine and severe protein-calorie malnutrition. R38's Minimum Data Set (MDS) assessment, dated 7/2/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R38 had moderately impaired cognition. R38 was R38's own decision maker. R38's medical contained an Informed Consent to Receive the Influenza, Pneumococcal 23, Prevnar 13, Pneumococcal 15 or 20, RSV Vaccine and COVID-19 Vaccines form signed by R38 and dated 6/27/25. The form indicated R38 consented to receive all available vaccinations. A physician order form, dated 8/20/25, indicated R38 could receive the RSV and Prevnar 20 vaccines and a COVID-19 booster. The form indicated to administer the RSV and Prevnar 20 vaccines now and the COVID-19 booster with an influenza vaccine when available. Surveyor noted R38 received an RSV vaccine at the facility on 9/10/25 but the Prevnar 20 vaccine was left blank. R38's medical record did not indicate R38 received the Prevnar 20 vaccine. 2. On 9/16/25, Surveyor reviewed R35's medical record. R35 admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), renal insufficiency, end-stage renal disease (ESRD), diabetes mellitus, and chronic obstructive pulmonary disease (COPD). R35's MDS assessment, dated 7/29/25, had a BIMS score of 12 out of 15 which indicated R35 had moderately impaired cognition. R35 was R35's own decision maker. R35's medical record contained an Informed Consent to Receive the Influenza, Pneumococcal 23, Prevnar 13, Pneumococcal 15 or 20, RSV Vaccine and COVID-19 Vaccines form signed by R35 and dated 7/29/25. The form indicated R35 consented to receive all available vaccines. A physician's order form, dated 8/20/25, indicated R35 could receive the RSV and Prevnar 20 vaccines and COVID-19 booster. The form indicated to administer the RSV and Prevnar 20 vaccines now and give the COVID-19 booster with an influenza vaccine when available. R38's medical record did not indicate R38 received the Prevnar 20 or RSV vaccines. 3. On 9/16/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation (A-fib), dementia, and other cerebral infarction due to occlusion or stenosis of small artery. R8's MDS assessment, dated 8/1/25, had a BIMS score of 0 out of 15 which indicated R8 had severely impaired cognition. R8 had an activated Power of Attorney for Healthcare (POAHC).R8's medical record contained an Informed Consent to Receive the Influenza, Pneumococcal 23, Prevnar 13, Pneumococcal 15 or 20, RSV Vaccine and COVID-19 Vaccines form signed by R8's POAHC and dated 5/15/25. The form indicated R8's POAHC gave consent for R8 to receive all available vaccinations. A physician's order form, dated 8/18/25, recommended R8 receive an RSV vaccine and a COVID-19 booster. A response from the physician, dated 8/20/25, indicated R8 could receive an RSV vaccine and COVID-19 booster. R8's medical record did not indicate R8 received a Prevnar 20 vaccine. An order for R8 to receive a Prevnar 20 vaccine was not obtained. On 9/16/25 at 1:12 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R38, R35, and R8 had not received the requested vaccines possibly because the orders stated to give the vaccines when influenza vaccines were received by the facility. NHA-A indicated NHA-A and Director of Nursing (DON)-B order vaccines and work to ensure vaccines are provided to residents who consent to receive them. On 9/16/25 at 3:08 PM, NHA-A approached Surveyor and indicated DON-B called the pharmacy last week because the facility had not received the Prevnar vaccine. NHA-A requested DON-B follow-up with the pharmacy and indicated the orders for the requested vaccines were not correct which is why the vaccines didn't arrive.On 9/16/25 at 3:15 PM, Surveyor interviewed DON-B who indicated DON-B called a few minutes ago to check on the Prevnar vaccines and realized the Prevnar vaccines ordered a week ago or so were not ordered correctly. DON-B indicated DON-B realized the order had to be submitted a different way and on a different form. DON-B indicated DON-B would look for the order for R8's request for the Prevnar vaccine and provide the order to Surveyor. DON-B indicated a week or so ago was the first time the facility attempted to order the Prevnar vaccine.On 9/16/25 at 3:45 PM, DON-B approached Surveyor and indicated RSV and COVID-19 vaccines were administered to R8 on 9/10/25, however, an order for the Prevnar vaccine was not obtained. DON-B indicated the facility would obtain the order and ensure all vaccines were ordered and administered. On 9/17/25 at 11:43 AM, Surveyor interviewed NHA-A who confirmed an order for R8's Prevnar 20 vaccine was not obtained and there was a miscommunication between the facility and the pharmacy which caused a delay in ordering and receiving vaccines that should have been administered to residents. NHA-A indicated all vaccines were ordered and residents will receive the vaccines when the pharmacy delivers them the next day.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R33) of 7 sampled residents received education regarding the risks and benefits of a COVID-19 vaccine and did not ensure the vaccine was administered. R33 requested to receive a COVID-19 vaccine. The facility did not transcribe a physician's order for the vaccine or administer the vaccine per R33's request.Findings include:The facility's General Immunization/Vaccination policy, revised 3/30/25, indicates: It is the guidelines of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases .7. Following an assessment for potential medical contraindications, the specified vaccination(s) may be administered in accordance with physician-approved standing orders if such are used, or a practitioner order is obtained .8. COVID-19 Immunization: a. Residents and staff will be offered the COVID-19 vaccine when supplies are available to the facility.On 9/16/25, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including spondylosis without myelopathy or radiculopathy, cervical region, mild protein-calorie malnutrition, diabetes with diabetic neuropathy, and chronic obstructive pulmonary disease (COPD). R33's Minimum Data Set (MDS) assessment, dated 8/23/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R33 had intact cognition. R33 was R33's own decision maker. R33's medical record contained an Informed Consent to Receive the Influenza, Pneumococcal 23, Prevnar 13, Pneumococcal 15 or 20, RSV Vaccine and COVID-19 Vaccines document, dated 2/20/25 and signed by R33, that indicated R33 consented to all available vaccines. A physician's order sheet, dated 8/20/25, indicated R33 could receive a COVID-19 and RSV vaccine. R33's medical record did not indicate the COVID-19 or RSV vaccines were administered. Surveyor requested a copy of R33's immunization record from Nursing Home Administrator (NHA)-A and physician orders for administration of the vaccines.On 9/17/25, NHA-A provided Surveyor with R33's original consent for the vaccines as well as a progress note, dated 9/17/25, that indicated NHA-A verified with R33 that R33 did not receive any vaccines in the last 30 days. NHA-A explained to R33 the physician order to administer the vaccines was missed and the COVID-19 and RSV vaccines were ordered on 9/17/25. On 9/17/25 at 11:43 AM, Surveyor interviewed NHA-A who verified the facility did not process the order for R33's COVID-19 and RSV vaccines. NHA-A confirmed consent for administration of vaccines was signed upon admission by R33 and a physician order to administer the vaccines was obtained but not processed. NHA-A indicated COVID-19 and RSV vaccines were last administered at the facility on 9/10/25 and verified the facility had supplies of the vaccines when R33 was admitted and signed consent to receive the vaccines.

Based on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R7) of 1 sampled resident. R7's physician was not updated when a reddened and painful skin area on R7's groin and scrotum worsened. Findings include: The facility's Notification of Changes policy, last reviewed 8/27/24, indicates: The facility must inform the resident, consult with the resident's physician .when there is a change .3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition . From 3/11/25 to 3/12/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility with diagnoses including dementia, epilepsy, schizophrenia, anxiety, and traumatic brain injury. R7's Minimum Data Set (MDS) assessment, dated 2/22/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R7 had moderately impaired cognition. R7 had a Guardian who made medical decisions for R7. On 3/12/25, Nursing Home Administrator (NHA)-A provided documentation of 1:1 education signed and dated on 2/12/25 by NHA-A and Certified Nursing Assistant (CNA)-E that indicated CNA-E would provide care for R7's groin and scrotum slowly and more carefully. On 3/12/25 at 3:17 PM, Surveyor interviewed NHA-A who indicated R7 had redness and pain in the scrotum and groin area prior to the education provided to CNA-E. NHA-A provided documentation, dated 12/24/24, that R7's primary care provider ordered an antifungal powder to be applied to R7's groin and documentation that R7's care plan was updated with an intervention to allow R7 to wash R7's own peri area on 2/13/25. When Surveyor asked if R7's groin had worsened from 12/24/24 to 2/12/25 and if R7's physician should have been updated on 2/12/25, NHA-A indicated R7's physician should have been updated on 2/12/25 with R7's change in skin condition.

Based on staff and resident representative interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, and resolved for 1 resident (R) (R18) of 19 sampled residents. Guardian (GDN)-I (R18's court-appointed Guardian) submitted a grievance on 2/25/25 regarding concerns with cleanliness, R18's roommate, and showers. The grievance form indicated there was follow-up on 2/26/25, however, GDN-I indicated GDN-I was not updated regarding all components of the grievance and how the grievance was resolved. Findings include: The facility's Grievances policy, revised 10/22/24, indicates: It is the policy of this facility to provide a process to voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and respond with prompt efforts to resolve while keeping the resident and/or resident representative appropriately apprised of progress toward resolution .Our facility will promote the grievance process throughout the organization. This includes notifying residents of their rights related to grievances as well as educating all those affected by potential grievances or concerns of the facility's grievance process, including but not limited to, residents, resident representatives, employees, volunteers, vendors, and all other stakeholders .The Grievance Officer is the Nursing Home Administrator (NHA) and/or Designee appointed by the NHA. This individual is responsible for oversight of the grievance process in conjunction with facility administration and .receives and tracks all grievances through to their conclusion, leads necessary investigations, works with facility staff using a root cause analysis process for resolution of the grievance or concern .completes written grievance resolutions/decisions to the resident involved .Any employee of the facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved, the employee shall escalate the complaint to their supervisor and the Grievance Officer. Grievances will be recorded and logged . On 3/11/25, Surveyor reviewed the facility's grievance log and noted a grievance from GDN-I, dated 2/25/25, that indicated GDN-I informed NHA-A during a visit that R18 had food on R18's shirt, bedside table, and floor. Staff did not disinfect the table, change R18's soiled clothing, or clean the food off the floor. GDN-I also indicated R18's roommate was not appropriate for R18 and requested a different roommate or a private room. In addition, GDN-I indicated R18 had not received a shower and GDN-I requested R18 receive two showers per week. The grievance form indicated staff education was provided on changing soiled clothing and R18 was scheduled for two weekly showers. Education was also provided to housekeeping staff. The form indicated the grievance was resolved on 2/26/25 at 12:00 AM and the resolution was reported to GDN-I the same day. A note on the grievance indicated R18 was in a new room and refused showers. From 3/11/25 to 3/12/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility for rehab and had diagnoses including dementia, Alzheimer's disease, diabetes type 2, schizoaffective disorder, and bipolar disorder. R18's Minimum Data Set (MDS) assessment, dated 2/25/25, indicated R18 had severely impaired cognition. On 3/12/25 at 10:35 AM, Surveyor interviewed GDN-I who indicated the grievance was submitted the first day GDN-I visited R18. GDN-I indicated GDN-I entered R18's room after lunch and saw breakfast food on R18 and the floor. GDN-I indicated R18 had been at the facility for over a week and had not had a shower. GDN-I requested R18 have two showers per week because R18 looked unkept. GDN-I also indicated R18's roommate was inappropriate for R18 due to behavioral concerns and requested a room change for R18 which was granted. GDN-I indicated NHA-A stated NHA-A would talk to staff, however, GDN-I was not informed of what was discovered during the investigation, was not sure if there were any actions taken to correct the concerns, and was not provided follow-up or a resolution. GDN-I indicated there had been some improvement, however, GDN-I's cleanliness concern was not fully addressed and GDN-I did not know if there were interventions implemented to prevent the concerns from occurring in the future. On 3/12/25 at 2:38 PM, Surveyor interviewed NHA-A who indicated NHA-A spoke with GDN-I on the day the concern was reported and informed GDN-I what would be done. NHA-A indicated NHA-A considered that follow-up for the concerns. NHA-A indicated a room change occurred and NHA-A spoke with staff regarding the concerns. NHA-A indicated NHA-A updated GDN-I about the room change and shower schedule change the following Monday (3/3/25) and indicated all follow-up information was contained on the grievance form. NHA-A did not indicate why the follow-up was documented at 2/26/25 at 12:00 AM, and did not provide any further follow-up or resolution for the grievance.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R1) of 19 sampled residents. R1 indicated Certified Nursing Assistant (CNA)-E was abusive to R1. R1 reported the incident to staff. The allegation of abuse was not reported to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated 12/2/24, indicates: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . From 3/11/25 to 3/12/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including cerebrovascular accident (stroke), left hemiparesis, dysphagia, and diabetes. A Minimum Data Set (MDS) assessment, dated 1/11/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderately impaired cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). On 3/11/25 at 5:08 PM, Surveyor interviewed R1 who indicated via writing and demonstration that CNA-E had grabbed and twisted R1's right wrist which caused R1 pain. R1 indicated R1 felt the abuse was purposeful. R1 indicated R1 reported the incident to an unidentified staff member and R1's POAHC. On 3/12/25 at 10:15 AM, Surveyor interviewed R1's POAHC (POAHC-J) who indicated R1 reported the physical abuse during the summer of 2024. POAHC-J indicated POAHC-J reported the incident to Registered Nurse (RN)-G and Licensed Practical Nurse (LPN)-H. POAHC-J indicated POAHC-J did not receive any follow-up regarding the allegation of abuse. On 3/12/25 at 2:04 PM, Surveyor interviewed RN-G who indicated RN-G did not recall R1's allegation that CNA-E twisted R1's right wrist. Surveyor was unable to interview LPN-H during the survey. On 3/12/25 at 2:38 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who denied any knowledge of R1's allegation of abuse and indicated the allegation of abuse was not reported to the SA or local law enforcement.

Based on staff and resident representative interview and record review, facility did not thoroughly investigate an allegation of abuse for 1 resident (R) (R1) of 19 sampled residents. R1 and R1's Power of Attorney for Healthcare ((POAHC)-J) reported an allegation of physical abuse to staff that involved Certified Nursing Assistant (CNA)-E. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 12/2/24, indicates: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; .3 Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . From 3/11/25 to 3/12/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including cerebrovascular accident (stroke), left hemiparesis, dysphagia, and diabetes. R1's Minimum Data Set (MDS) assessment, dated 1/11/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderately impaired cognition. R1 had an activated POAHC. On 3/11/25 at 5:08 PM, Surveyor interviewed R1 who indicated via writing and demonstration that CNA-E had grabbed and twisted R1's right wrist which caused R1 pain. R1 indicated R1 felt the abuse was purposeful. R1 indicated R1 reported the incident to an unidentified staff member and R1's POAHC. On 3/12/25 at 10:15 AM, Surveyor interviewed POAHC-J who indicated R1 reported allegation of physical abuse in the summer of 2024. POAHC-J indicated POAHC-J reported the incident to Registered Nurse (RN)-G and Licensed Practical Nurse (LPN)-H. POAHC-J indicated POAHC-J did not receive any follow-up on the allegation of abuse. On 3/12/25 at 2:04 PM, Surveyor interviewed RN-G who indicated RN-G did not recall R1's allegation that CNA-E twisted R1's right wrist. Surveyor was unable to interview LPN-H during the survey. Surveyor noted the facility did not obtain statements from R1 and CNA-E as well as other residents and staff and did not thoroughly investigate the allegation of abuse. On 3/12/25 at 2:38 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who indicated NHA-A and DON-B both investigate resident concerns. NHA-A and DON-B indicated neither were aware of an allegation of physical abuse involving R1 and CNA-E.

Based on staff interview and record review, the facility did not ensure showers, feeding assistance, and activities of daily living (ADLs) were performed by a qualified person for 2 residents (R) (R15 and R19) of 19 sampled residents. This practice had the potential to affect more than 4 of the 41 residents residing in the facility. The facility did not ensure Hospitality Aide (HA)-D performed responsibilities that were within HA-D's scope of practice when HA-D assisted with showering, feeding, and transferring R15 and R19. Findings include: On 3/11/25 at 6:26 PM, Surveyor interviewed R15 who indicated HA-D completed cares, showers, and transfers for R15 and assisted with washing and getting R15 dressed. (R15 wished to remain anonymous. R15's most recent Minimum Data Set (MDS) assessment indicated R15 was not cognitively impaired.) On 3/12/25, Surveyor reviewed the job description and responsibilities for Hospitality Aides provided by Nursing Home Administrator (NHA)-A. Surveyor reviewed a Hospitality Aide document, signed by HA-D on 1/29/25, that indicated: To provide support and assistance to Nursing Department .Essential Functions .Makes beds, labels clothing and belonging, completes admission and discharge inventory lists, distributes laundry, passes meal trays, offers basic tray set up. May assist with feeding, if competency demonstrated .answers call lights - provides only basic assistance .no hands-on care allowed. On 3/12/25 at 11:56 AM, Surveyor interviewed HA-D who indicated HA-D's job responsibilities included 1:1 supervision with residents and assisting with passing water and meal trays. HA-D indicated HA-D could not do personal cares. HA-D confirmed HA-D has functioned as the second person for lifts and transfers and has assisted with feeding, dressing, and grooming residents. HA-D indicated HA-D has given showers, including for R19 who mostly showered independently, and was in the shower room alone with R19. HA-D indicated HA-D does not do a lot of peri-care and just assists with positioning in bed during cares. HA-D confirmed HA-D was not a Certified Nursing Assistant (CNA) and did not receive education related to providing cares or feeding and transferring residents. On 3/12/25 at 12:30 PM, Surveyor requested trainings and competencies HA-D had completed for HA-D's position. On 3/12/25 at 12:40 PM, Surveyor interviewed R19 who indicated HA-D assisted with R19's shower. R19 indicated R19 washed R19's self independently but required the assistance of HA-D to dress and dry off and to transfer with a Hoyer lift. R19 indicated HA-D has assisted R19 with washing and dressing from time to time. On 3/12/25, Surveyor reviewed R19's medical record. R19 had diagnoses including traumatic spinal cord injury with paraplegia, neurogenic bladder with placement of indwelling catheter, and type 2 diabetes. R19's MDS assessment, dated 1/18/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R19 was not cognitively impaired. On 3/12/25 at 2:38 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B who indicated neither were aware HA-D had fed residents. NHA-A and DON-B indicated HA-D did not receive training or complete a competency to feed residents. NHA-A and DON-B confirmed HA-D should not shower or be alone with residents in the shower room even if the resident are able to wash independently. NHA-A and DON-B confirmed it is out of HA-D's scope of practice to assist with dressing (other than to hand items to residents), wash residents, provide cares, and be the second staff for lifts and transfers.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R10) of 1 resident observed during the provision of cares. R10 had an indwelling catheter and was on enhanced barrier precautions (EBP). On 3/11/25, Certified Nursing Assistant (CNA)-E and CNA-F did not wear gowns while completing personal hygiene and catheter care for R10. In addition, Registered Nurse (RN)-G did not wear a gown or complete hand hygiene between glove changes during wound care for R10. Finding include: The facility's Enhanced Barrier Precautions policy, dated 2/5/25, indicates: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident cares .initiation of EBP: .i. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) .Implementation of EBP: a. Make gowns and gloves available immediately near or outside the resident's room .4. High-contact resident cares include: a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: .urinary catheters .h. wound care: any skin opening requiring a dressing . The facility's Hand Hygiene policy, dated 5/29/24, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection .hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as an alcohol-based hand rub (ABHR) .Hand hygiene is indicated and will be .performed before and after handling clean or soiled dressings, linens, etc., during resident care, moving from a contaminated body site to a clean body site, after handling contaminated items with blood, body fluids, secretions or excretions .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . From 3/11/25 to 3/12/25, Surveyor reviewed R10's medical record. R10 had diagnoses including quadriplegia, diabetes, polyneuropathy, and a pressure ulcer. R10 had an indwelling urinary catheter and an ostomy. R10's Minimum Data Set (MDS) assessment, dated 2/19/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 was not cognitively impaired. On 3/11/25 at 7:03 PM, Surveyor observed an EBP sign posted on R10's door but noted there were no gowns near or outside R10's door. Surveyor entered the room and observed CNA-E provide catheter care without a gown. CNA-F then entered the room without a gown and assisted CNA-E with peri-care. After the provision of peri-care, CNA-E and CNA-F changed R10's brief. On 3/11/25 at 7:45 PM, Surveyor observed RN-G provide wound care for R10. RN-G washed hands and donned gloves but did not don a gown. RN-G removed R10's dressing and removed gloves. Without complete hand hygiene, RN-G donned clean gloves. RN-G cleansed R10's wound with saline and blotted the wound with gauze. RN-G then changed gloves without completing hand hygiene. RN-G applied Medihoney, zinc, and antifungal ointment to the wound with a tongue depressor and changed gloves without completing hand hygiene. RN-G then retrieved tape and washed hands with soap and water. RN-G donned clean gloves, put a dressing over R10's wound, taped the dressing in place, and removed gloves. Without completing hand hygiene, RN-G donned clean gloves, put a treatment in R10's anal cavity, applied a clear dressing over the area, and removed gloves. RN-G then washed hands with soap and water. On 3/11/25 at approximately 8:20 PM, Surveyor interviewed CNA-E who stated CNA-E should have worn a gown during cares for R10. Surveyor also interviewed CNA-F who indicated a gown should be worn during catheter care. On 3/11/25 at 8:35 PM, Surveyor interviewed RN-G who indicated RN-G should have washed hands between gloves changes and should have worn a gown during wound care for R10. On 3/12/25 at 10:15 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R10 was on EBP and CNA-E and CNA-F should have worn gowns during high-contact resident care. DON-B indicated RN-G should have worn a gown during wound care and completed hand hygiene every time RN-G removed gloves. DON-B indicated Nursing Home Administrator (NHA)-A was also the facility's Infection Preventionist. On 3/12/25 at 11:18 AM, Surveyor interviewed NHA-A who indicated R10 was on EBP and CNA-E and CNA-F should have worn gowns while providing hygiene care for R10. NHA-A also indicated RN-G should have worn a gown and completed hand hygiene in between glove changes during wound care. NHA-A provided R10's care plan (initiated on 1/14/25) which indicated R10 was on EBP due to an indwelling urinary catheter, ostomy, and wounds. NHA-A indicated there should be a personal protective equipment (PPE) cart with gowns outside R10's room.

Based on staff and resident representative interview and record review, the facility did not ensure a physician and Guardian were notified of medication refusals for 1 resident (R) (R3) of 11 sampled residents. R3 refused multiple medications in January and February of 2025. The facility did not notify R3's physician or Guardian. Findings include: The facility's Medication Administration policy, dated 1/2024, indicates: .2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .If two consecutive doses of a vital medication are withheld or refused, the physician is notified. On 2/12/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, hypertension, obsessive compulsive disorder (OCD), depression, disruptive mood dysregulation disorder, personality disorder, and dysphagia (difficulty swallowing). R3's Minimum Data Set (MDS) assessment, dated 12/16/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R3 had moderately impaired cognition. R3 had a corporate Guardian for decision making. R3's medical record indicated R3 was prescribed the following medications and refused the following medications at least twice in a row without physician notification: Aspirin 81 milligram (mg) chewable tablet once daily for heart health ~Refused 1/2/25, 1/3/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Atorvastatin 10 mg once daily for hypertension ~Refused 1/26/25, 1/27/25, 2/5/25, 2/6/25, 2/8/25, and 2/9/25 Divalproex Sodium Extended Release 24 hour 500 mg (4 tablets) once daily for OCD ~Refused 1/26/25, 1/27/25, 2/5/25, 2/6/25, 2/8/25, and 2/9/25 Fluoxetine HCL 20 mg once daily for depression ~Refused 1/2/25, 1/3/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Hydrochorothiazide 12.5 mg once daily for hypertension ~Refused 1/2/25, 1/3/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Hydroxyzine 25 mg in AM and 12.5 mg in PM once daily for personality disorder ~Refused (PM dose) 1/26/25, 1/27/25, 2/5/25, 2/6/25, 2/8/25, and 2/9/25 ~Refused (AM dose) 1/2/25, 1/3/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Losartan 100 mg once daily for hypertension ~Refused 1/2/25, 1/3/25, 1/4/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Norvasc 10 mg once daily for hypertension ~Refused 1/2/25, 1/3/25, 1/4/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Pantoprazole 40 mg once daily for gastroesophageal reflux disease (GERD) ~Refused 1/2/25, 1/3/25, 1/4/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Potassium oral tablet once daily for hypokalemia ~Refused 1/2/25, 1/3/25, 1/4/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 Risperidone 1 mg in AM and 2 mg in PM once daily for personality disorder ~Refused AM dose 1/2/25, 1/3/25, 1/4/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 ~Refused PM dose 1/5/25, 1/6/25, 1/8/25, 1/9/25, 1/26/25, and 1/27/25 Metformin 500 mg twice daily for diabetes mellitus type 2 ~Refused AM dose 1/2/25, 1/3/25, 1/4/25, 1/12/25, 1/13/25, 1/14/25, 1/17/25, and 1/18/25 R3's medical record did not include physician or Guardian notification for R3's medication refusals. On 2/12/25 at 12:31 PM, Surveyor interviewed R3's Guardian ((GD)-D) who was not aware R3 had been refusing medication and indicated medication refusals were not discussed at R3's care conference on 2/4/25. On 2/12/25 at 2:30 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should have contacted R3's physician regarding R3's medication refusals. DON-B indicated notification should occur after 3 medication refusals.

Based on observation, staff and resident representative interview, and record review, the facility did not provide treatment and services to prevent weight loss and hydration for 2 residents (R) (R3 and R1) of 11 sampled residents. R3 had an order for a mechanical soft diet with ground meat. On 12/20/24, a swallow study and speech therapy evaluation was requested for a possible diet upgrade. On 12/30/24, Speech Therapy (ST) upgraded R3's diet, however, R3's diet order was not changed. As of 2/12/25, the swallow study was not completed. In addition, R3's meal intakes were not consistently documented. R1 was at risk for dehydration. Staff did not consistently document or monitor R1's fluid intake to determine if hydration interventions were effective. Findings include: The facility's Nutritional Management policy, dated 4/9/24, indicates: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment .IV. Food and fluid intake. The facility's Hydration (Food/Fluid) Monitoring policy, dated 10/30/24, indicates: .6. Record beverage intake in designated locations. 1. On 2/12/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including visual loss both eyes, unspecified sensorineural hearing loss, moderate intellectual disability, obsessive compulsive disorder (OCD), disruptive mood dysregulation disorder, personality disorder, and dysphagia (difficulty swallowing). R3's Minimum Data Set (MDS) assessment, dated 12/16/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R3 had moderately impaired cognition. R3 had a corporate Guardian for decision making. R3's medical record indicated R3's admission weight on 11/5/24 was 169.4 pounds (lbs). Upon admission, R3 had an order for a mechanical soft diet with ground meat. R3's last weight on 1/22/25 was 158.4 lbs. A quarterly assessment, dated 2/4/25, indicated R3 had a 7.3% weight loss in 3 months. (A significant weight loss is considered 7.5% in 3 months.) Surveyor reviewed R3's meal intakes for January and February of 2025 and noted approximately 20% of R3's intakes were not documented in January and approximately 33% of R3's intakes were not documented in February. The intakes that were documented noted the percentage of the meal that R3 ate or if R3 refused the meal. Communication to R3's physician on 12/20/24 indicated R3 had an order for a regular mechanical soft diet with ground meat. R3 did not like ground meat and requested regular food. An order/referral for a swallow study was requested to see if R3's diet could be upgraded. A Nurse Practitioner (NP) gave an order for a ST evaluation for a potential diet upgrade from ground meat. On 12/30/24, ST evaluated R3 and recommended a mechanical soft diet with cut up meat. A progress note, dated 2/4/25, indicated R3's family expressed concern at a care conference that R3 had lost weight and was not receiving meals. Registered Dietitian (RD)-F was aware of R3's weight loss. Director of Nursing (DON)-B was awaiting a response regarding starting a house supplement. The note indicated R3 refused meals at times and staff offered alternatives. R3's family was not aware R3 was on a mechanical soft diet. The team discussed asking R3's physician to order a swallow study to see if R3's swallowing issues had resolved and if R3's diet could be upgraded. On 2/12/25 at 11:50 AM, Surveyor observed staff deliver a meal tray to R3's room. R3's meal ticket indicated R3 should receive a mechanical soft diet with ground meat. Surveyor noted R3's tray contained ground meat with gravy. R3 refused lunch and indicated to staff that R3 had a big breakfast. On 2/12/25 at 12:31 PM, Surveyor interviewed R3's Guardian ((GD)-D) who indicated R3 was supposed to have a swallow study as indicated during R3's care conference on 2/4/25. GD-D had not heard if a swallow study was scheduled. GD-D also did not know R3 was prescribed a diet with ground meat. GD-D indicated R3 ate a regular diet prior to getting sick and GD-D thought the ground meat order originated when R3 was in the hospital. GD-D indicated a family member bought R3 a hamburger which R3 ate with no concerns. GD-D indicated R3 should be upgraded to a regular diet so R3 will want to eat and not lose weight. On 2/12/25 at 12:45 PM, Surveyor interviewed Speech Therapist (ST)-E who saw R3 on two occasions upon admission. ST-E received a referral in mid-December to see if R3's diet could be upgraded. ST-E saw R3 on 12/30/24 and recommended an upgrade from ground meat to cut up meat. ST-E filled out a physician order form with the recommendation. The form, dated 12/30/24, contained a diet clarification order for a mechanical soft diet with cut up meat. ST-E indicated ST-E sent a copy of the form to R3's nurse and the kitchen. ST-E indicated ST-E received a referral that morning (2/12/25) to evaluate R3 for a diet upgrade but thought ST-E evaluated R3 a month and a half ago. When asked about the swallow study, ST-E stated swallow studies go through the physician and the resident is scheduled for an outside appointment. On 2/12/25 at 1:14 PM, Surveyor interviewed RD-F who indicated RD-F completed R3's quarterly evaluation and noted R3 was close to a significant weight loss since admission. RD-F requested that R3 start a supplement. RD-F was not aware that R3 was evaluated on 12/30/24 by ST and that ST had requested a diet upgrade. When asked if RD-F was aware that swallow studies were requested to see if R3's diet could be upgraded, RD-F stated RD-F was not aware. When informed that R3's intakes were not documented consistently, RD-F confirmed staff should document intakes for each meal because RD-F uses the documentation for assessments. On 2/12/25 at 2:30 PM, Surveyor interviewed DON-B who reviewed the communication to the physician in December regarding a diet upgrade for R3. DON-B indicated a swallow study was not scheduled. DON-B indicated staff notified R3's physician after a care conference on 2/4/25 and requested an ST evaluation and swallow study. DON-B indicated the physician replied to have ST evaluate R3 but did not address the swallow study. DON-B indicated staff who received the reply should have contacted the physician directly to address the swallow study. DON-B reviewed the request on 12/20/24 and verified the physician ordered an ST evaluation for R3 but did not address the swallow study then either. DON-B was not aware ST saw R3 on 12/30/24 and recommended a diet upgrade. DON-B indicated R3's new diet order should have been implemented. DON-B also indicated staff should document meal intakes for all residents' meals. 40342 2. On 2/12/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, amputation of right hand, and hemiplegia (paralysis/immobility of one side of the body) following cerebral infarction (also known as stroke) affecting the left side. R1's MDS assessment, dated 1/25/25, indicated R1 was rarely/never understood. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1's care plan indicated R1 required total assistance with eating. R1's care plan also indicated R1 had dehydration and a potential for fluid deficit and contained an intervention (dated 11/22/24) to offer fluids to R1 hourly. On 2/12/25, Surveyor observed staff offer and provide R1 with fluids on an hourly basis On 2/12/25, Surveyor reviewed Certified Nursing Assistant (CNA) documentation of R1's fluid intake each shift from 1/1/25 through 2/11/25. R1's medical record indicated R1 was hospitalized for three days in January. Of the 118 shift opportunities for documentation, 67 shifts had missing fluid intake documentation which indicated 56.78% of shifts were missing documentation. On 2/12/25 at 1:49 PM, Surveyor interviewed DON-B who indicated staff should offer fluids to R1 every 30 minutes to an hour. DON-B indicated R1 usually accepts fluids when offered. DON-B indicated CNAs are expected to document R1's fluid intake every shift and nurses are expected to ensure the documentation is completed timely. DON-B verified the missing documentation indicated above and stated, Makes it look like (R1) is not getting the fluid (R1) needs.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 2 residents (R) (R5 and R6) of 4 sampled residents. R5 did not receive calcium 200 milligrams (mg) as ordered during the AM medication pass on 2/12/25. In addition, staff did not update R5's physician regarding the missed medication. R6 did not receive Seroquel XR 50 mg as ordered during the AM medication pass on 2/12/25. Findings include: The facility's Medication Administration Policy, revised 11/12/24, indicates: .10. Ensure that the six rights of medication administration are followed .b. Right drug .11. Review Medication Administration Record (MAR) to identify medication to be administered .22. If medication is unable to be administered due to the unavailability of the medication, notify the pharmacy to obtain alternative medication options, to include contingency availability, and consult with the physician . 1. On 2/12/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including disorder of bone, pulmonary fibrosis (a serious lung disease that makes it hard for the lungs to function normally), chronic systolic heart failure, and bipolar disorder. A Minimum Data Set (MDS) assessment had not yet been completed for R5. R5 was responsible for R5's medical decisions. On 2/12/25 at 8:34 AM, Surveyor observed Licensed Practical Nurse (LPN)-C administer R5's medication. R5's AM medications included calcium 200 mg once daily (supplement). LPN-C indicated the calcium was not in the medication cart. LPN-C checked other areas in the facility and indicated the facility was out of calcium 200 mg. LPN-C updated the staff who ordered medication and marked the calcium as not administered. LPN-C did not notify R5's physician. On 2/12/25 at 12:21 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated LPN-C should have followed the facility's Medication Administration Policy and updated the physician that R5's calcium 200 mg was not administered because it was not available. 2. On 2/12/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including Hirschsprung disease (a rare birth defect that prevents stool from moving normally through the large intestine), chronic obstructive pulmonary disease (COPD), anxiety, depression, and schizoaffective disorder. An MDS assessment had not yet been completed for R6. R6 was responsible for R6's medical decisions. On 2/12/25 at 9:03 AM, Surveyor observed LPN-C administer R6's medication. LPN-C indicated there was no Seroquel in the medication cart for R6. LPN-C removed quetiapine (generic equivalent of Seroquel) from the facility's contingency stock and administered the medication to R6. LPN-C showed the medication to Surveyor which was quetiapine 25 mg. LPN-C indicated LPN-C gave two 25 mg tablets to R6 which equaled the 50 mg dose that was ordered. On 2/12/25 at approximately 10:00 AM, Surveyor reviewed R6's medical record and noted R6 had an order for Seroquel XR (extended release) 50 mg give 1 tablet by mouth once daily for schizoaffective disorder. On 2/12/25 at approximately 11:30 AM, Surveyor interviewed LPN-C who indicated the quetiapine that LPN-C administered to R6 was not extended release. LPN-C indicated LPN-C would update the physician regarding the medication error. On 2/12/25 at 12:21 PM, Surveyor interviewed DON-B who indicated LPN-C administered an incorrect medication to R6 which resulted in a medication error.

Based on resident and staff interview and record review, the facility did not allow 1 resident (R) (R2) of 3 sampled residents to set up a petty cash fund or Resident Fund Management Service (RFMS) account. R2's Corporate Guardian (CG)-H asked the facility to set up a resident account for R2. CG-H was told an account could not be set up and the facility could not cash checks for R2 unless CG-H provided direct deposit account information. Findings include: The facility's Resident Personal Funds policy, revised 7/4/24, indicates: .2) If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. Deposit of Funds: .3) Residents whose care is funded by Medicaid; the facility will deposit the residents' personal funds in excess of $50 in an interest-bearing account separate from any of the facility's operating accounts, and that credits all interest earned on residents' funds to that account .4) The facility will maintain personal funds that do not exceed $50 in a non-interest bearing account, or petty cash fund. On 11/22/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, schizophrenia, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 8/27/24, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R2 had severely impaired cognition. R2 had a corporate guardian. On 11/22/24 at 9:11 AM, Surveyor interviewed Business Office Manager (BOM)-E regarding the facilty's RFMS. BOM-E indicated a resident's name is entered in the system and the resident or their representative sign documentation that gives approval for the facility to establish an account via direct deposit. BOM-E indicated residents and/or their representatives can also provide cash, checks, and money orders that BOM-E can put in the account. BOM-E indicated the facility accepts corporate guardian accounts and verified BOM-E and Social Worker (SW)-F had been in contact with CG-H. BOM-E verified R2 had asked about money and indicated R2 did not have an account because CG-H had not been responsive to R2's needs. BOM-E indicated the facility was unable to open an account for R2 because CG-H stated the guardianship organization could not give out bank account information for direct deposit. BOM-E verified CG-H had sent two fifty dollar checks to the facility for R2. BOM-E stated the facility could not process the checks because CG-H had not signed the facility's RFMS authorization agreement. BOM-E indicated an account could be established for R2 if CG-H responded appropriately and indicated the facility could not open an account for R2 from the documentation. BOM-E confirmed both checks were returned to CG-H. On 11/22/24 at 11:49 AM, Surveyor interviewed BOM-E who indicated the facility could not set up an account that did not require an automatic transfer. BOM-E indicated once the account was established, the facility had the legal authority to cash checks, however, the facility could not cash checks until that time. On 11/22/24 at 12:49 PM, Surveyor interviewed BOM-E who confirmed the facility did not have a process to receive checks/cash and create petty cash accounts for residents. BOM-E indicated it was not the facility's responsibility and was up to the guardian. BOM-E indicated a petty cash account was available if a direct deposit account was established by the guardian. BOM-E indicated the facility cannot manage all residents' finances without any type of legality and would be unable to manage petty cash accounts for multiple residents. BOM-E was not sure how R2 could have access to money and indicated the only thing the facility could do was provide the RFMS form for CG-H to sign. On 11/22/24 at 1:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who asked how the facility could track R2's petty cash account if R2 didn't already have a bank account. NHA-A verified the facility had a petty cash tracking process and indicated NHA-A was new and still learning. NHA-A verified if residents ask the facility to handle funds, the facility should handle their funds. On 11/22/24 at 1:51 PM, Surveyor interviewed R2 who indicated R2 wanted to be like everybody else and be able to buy things, including soda. R2 indicated R2 did not know how to obtain an account but would like to have one. R2 also stated R2 had no other money and would like if the facility could help R2 establish an account.

Based on observation, staff interview, and record review, the facility did not ensure services were provided to prevent further decrease in range of motion for 1 resident (R) (R1) of 8 sampled residents. R1's plan of care did not contain interventions to address R1's contracted left hand. Findings include: On 11/22/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, amputation of right hand, and hemiplegia (paralysis/immobility of one side of the body) following cerebral infarction (also known as stroke) affecting the left side. R1's Minimum Data Set (MDS) assessment, dated 10/26/24, indicated R1 was rarely/never understood. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. On 11/22/24 at 9:11 AM, Surveyor observed R1 in bed. Surveyor noted R1 had a below-the-elbow amputation of the right arm and R1's left hand/fingers were contracted and contained a rolled up wash cloth. On 11/22/24, Surveyor reviewed R1's care plan which did not address R1's left hand contracture. On 11/22/24 at 2:47 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R1's care plan did not address R1's left hand contracture. NHA-A indicated the facility's MDS nurse had been working on it. NHA-A indicated R1 used to be able to open R1's left had a little bit. NHA-A indicated therapy staff were going to find a piece of foam to place in R1's left hand and staff were using a wash cloth in the meantime. NHA-A verified R1's care plan should have included interventions to prevent R1's left hand contracture from worsening. On 11/26/24, Hospice RN (HRN)-G returned Surveyor's call from 11/22/24. On 11/26/24 at 8:15 AM, Surveyor interviewed HRN-G who verified HRN-G was R1's primary Hospice nurse. HRN-G indicated a Hospice Certified Nursing Assistant (CNA) who was assigned to R1 updated HRN-G during the first week of November (2024) that the Hospice CNA had to clean green slime out of the palm of R1's left hand and that the odor from R1's left hand was stinky. HRN-G indicated HRN-G assessed R1's hand after the Hospice CNA provided care and found no redness or open wound. HRN-G placed a wash cloth in R1's left hand. HRN-G indicated HRN-G informed facility staff of the Hospice CNA's report at a care conference held on 11/13/24.

Based on observation, staff interview, and record review, the facility did not consistently monitor nutrition/hydration intake for 1 resident (R) (R1) of 3 sampled residents. R1 had orders for one-on-one feeding assistance and meal and fluid intake to be documented each meal. Staff did not consistently document those items. In addition, R1's care plan was not updated with an intervention for staff to offer and provide R1 water every hour. Findings include: On 11/22/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, amputation of right hand, and hemiplegia (paralysis/immobility of one side of the body) following cerebral infarction (also known as stroke) affecting the left side. R1's Minimum Data Set (MDS) assessment, dated 10/26/24, indicated R1 was rarely/never understood. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1's medical record indicated R1 weighed 183.5 pounds (lbs) on 5/7/24. On 11/7/24, R1 weighed 156.5 lbs which was a 14.71 % weight loss. R1's care plan indicated R1 required total assistance with eating and contained an intervention, dated 8/20/24, to offer fluids to R1 frequently. On 11/22/24 at 9:11 AM, Surveyor observed R1 in bed and noted R1 had a below-the-elbow amputation of the right arm and a flaccid (soft and limp) left arm/hand. On 11/22/24, Surveyor reviewed a Grievance Report, dated 11/7/24, that indicated a Certified Nursing Assistant (CNA) brought a supper tray to R1's room. The Grievance report indicated the CNA returned 37 minutes later to feed R1 but just took the tray. The Grievance investigation indicated the facility educated staff on 11/8/24 and 11/14/24 to make sure R1 was fed even when family was present and to provide R1 with water every hour. The education forms contained a total of four different CNA signatures (two CNAs signed twice between the two dates). R1's medical record contained a note, dated 9/18/24, that indicated R1 was seen by Medical Director (MD)-C who indicated R1 should be one-on-one for meals to increase intake, should be evaluated and treated by the Registered Dietitian (RD) for a 10 lb weight loss, and staff should record R1's intakes. R1's medical record contained an RD note, dated 9/19/24, that indicated R1 triggered for significant weight loss, had orders for one-on-one for meals to monitor intake, and had no swallowing or chewing issues. In addition to other interventions, the RD recommended R1's supplement shake be increased from twice daily to three times daily to promote calorie intake. The RD also indicated staff should honor R1's food preferences whenever medically possible to maximize acceptance. Surveyor reviewed R1's September, October and November (2024) Treatment Administration Records (TARS) which contained orders for one-on-one for meals and record intake three times a day (effective 9/19/24). Surveyor noted there were two missing entries in September, six missing entries in October, and three missing entries in November. On 11/22/24 at 12:28 PM, Surveyor interviewed MD-C via phone. MD-C verified MD-C was the facility's Medical Director and R1's physician. MD-C indicated R1's order for one-on-one for meals was prompted by R1's family's concern of poor oral intake as well as R1's weight loss. MD-C indicated R1 was not able to consistently use R1's extremities. Surveyor reviewed CNA documentation of R1's fluid intake on each shift for September, October and November (2024). Surveyor noted there were 33 missing entries in September, 56 missing entries in October, and 25 missing entries in November. On 11/22/24 at 2:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A expects CNAs to document fluid intake every shift. NHA-A indicated the missing documentation meant R1 didn't receive anything and NHA-A could not prove R1 received fluids during those shifts. On 11/22/24 at 2:47 PM, Surveyor interviewed NHA-A who indicated staff should offer R1 something to drink, preferably water, at least once per hour. NHA-A verified R1's care plan did not indicate R1 should be offered/provided water every hour. When Surveyor indicated there were only four CNA signatures on the facility's education, NHA-A indicated the facility only had five CNA employees and used multiple agency CNAs. NHA-A verified if interventions were not on a resident's care plan, staff (including agency staff) would not know to complete the task. On 11/22/24 at 2:49 PM, Surveyor interviewed CNA-D who indicated R1 required staff assistance for meals and fluid intake as well as all other activities of daily living (ADLs). CNA-D indicated CNA-D was not aware that R1 should be offered fluid at least every hour.

Based on staff interview and record review, the facility did not provide adequate supervision to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. On 6/8/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to a location in another city that was 37 miles from the facility. On 6/14/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to the same location. On 7/30/24, R1 left the facility and was found by police walking on a county highway that was 1.4 miles from the facility. On 8/6/24, R1 exited the facility without signing out and was found by police after 9:00 PM walking into on-coming traffic on an interstate highway off-ramp that was over 1.5 miles from the facility. On 8/18/24, R1 left the facility and was found by police walking on a country road approximately 4 miles from the facility. The road was on the opposite side of the highway from the facility and there were overpasses which R1 likely walked under. The facility did not provide adequate supervision to prevent R1 from exiting the facility without signing out on 6/8/24, 6/14/24, and 8/6/24. In addition, the facility did not have a system to monitor R1's whereabouts (including on 7/30/24 and 8/18/24) despite the fact R1 refused to wear a Wanderguard and continually left the facility. The facility's failure to implement safety interventions for a resident and provide supervision to prevent the resident from exiting the facility without staff knowledge created a reasonable likelihood for serious harm which lead to a finding of Immediate Jeopardy (IJ) that began on 7/30/24. Nursing Home Administrator (NHA)-A was notified of the IJ on 8/27/24 at 4:58 PM. The IJ was removed on 8/28/24, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Elopements and Wandering Residents policy, with a revision date of 9/16/23, indicates: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk .If a resident is determined to be at risk for elopement or known to wander or elope: i. The resident's picture will be placed in the Wander Communication Binder. ii. If an alert bracelet system is used and deemed to be appropriate the bracelet will be applied .4. The Interdisciplinary Team (IDT), together with the resident's representative, should attempt to determine situations that may trigger a desire to leave and individual expressions in which staff should know could be a sign the resident may wander .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be evaluated for risk of elopement and unsafe wandering upon admission and throughout their stay by the IDT. b. The IDT will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the risk or to minimize risks associated with hazards will be added to the care plan and communicated to appropriate staff. d. Adequate supervision in accordance with evaluations will be provided to help prevent accidents or elopements .f. The effectiveness of interventions will be evaluated, and changes will be made as needed .8. Procedure Post-Elopement: a. A nurse will perform a physical evaluation, document, and report findings to the physician .c. A Social Services Designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults . On 8/27/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Huntington's disease (a neurodegenerative disease exhibited by problems with mood or mental abilities and a general lack of coordination), diabetes mellitus, chronic kidney disease, and depression. R1's Minimum Data Set (MDS) assessment, dated 6/3/24, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R1 had moderate cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1's care plan, dated 6/25/24, indicated R1 had decreased safety awareness and insight and contained the following interventions: ~ Arrange for transportation if R1 requests to go to appointments, the Department of Motor Vehicles (DMV), [NAME] Bay, etc. (initiated 7/22/24); ~ Continue to remind R1 to sign out when leaving the facility (initiated 8/6/24); ~ Distract R1 if agitated by offering pleasant diversions, structured activities, food, conversation, television, or book (initiated 6/25/24); ~ Identify pattern of behaviors: Is R1 looking for something? Does it indicate the need for more exercise? Intervene as appropriate (initiated 6/25/24); ~ Staff will inform local police if R1 has been away from facility over 2 hours (initiated 8/5/24). R1's care plan also indicated R1 had impaired cognitive function or thought processes, had difficulty distinguishing between television and reality, lacked understanding of distance between places, had decreased safety awareness (initiated 6/3/24) and was at risk for self-inflicted, life-threatening injury related to a history of suicidal intent (initiated 6/10/24) (related to an attempted suicide in 2015). R1's medical record contained the following assessments: ~ On 2/27/24, R1 was assessed at high risk for falls and low risk for elopement. ~ On 6/1/24, R1 was assessed at moderate risk for falls and low risk for elopement. ~ On 7/31/24, R1 was assessed at low risk for elopement. ~ On 8/20/24, R1 was assessed at low risk for elopement. Surveyor reviewed a Wander Communication Binder at the nurses' station. The binder contained pictures and information regarding three residents, but did not include R1. ~ A progress note, dated 6/8/24 at 3:53 PM indicated R1 ambulated out the front door pushing R1's wheelchair. R1 sat outside talking to other residents and then decided to leave the facility. Staff found R1 down the street walking toward Main Street. R1 stated the food was salty and R1 was heading to an emergency room (ER) in another city. R1 was brought back to the facility. Staff redirected R1 several times but R1 was fixated on going to another city and was placed on 15 minute checks. A corresponding police report, dated 6/8/24 at 6:30 PM, indicated staff reported that R1 was at a location on Main Street approximately 0.4 miles from the facility attempting to buy soda and staff needed R1 to return to the facility. An officer transported R1 back to the facility. Staff stated R1 had Huntington's disease and randomly left the facility when no one was looking. ~ Progress notes, dated 6/14/24 at 8:02 AM and 2:05 PM indicated R1 exited the front door, walked toward the bridge, and stated R1 was walking to a hospital. R1 was transported to the hospital for evaluation. R1 returned from the hospital at 2:00 PM and stated R1 would go back to the hospital if R1 was given any more antibiotics. ~ R1's medical record indicated between 6/15/24 and 6/30/24, R1 refused most oral medications but allowed insulin administration. A progress note, dated 6/17/24, indicated R1 stated R1 hoped R1 got a super big infection that puts me in the hospital. ~ An Examining Physician's Report (Adult Guardianship), dated 6/26/24, completed and signed by R1's physician, indicated R1 had Huntington's disease which caused progressive dementia and physical impairments, worsening memory, a flat affect, wandering and aggressive behavior, and R1 did not understand R1's memory or judgement impairments. The report indicated R1's incapacity was permanent and progressive. A SLUMS (St. Louis University Mental Status) Examination, dated 6/26/24, indicated R1 scored 12 (a score of 1-19 indicates dementia). ~ A police report, dated 7/11/24 at 5:31 PM, indicated at approximately 5:15 PM, an officer was dispatched to a business approximately 1.5 miles from the facility for a welfare check for R1 who stated R1 was a customer and walked 4 miles with R1's wheelchair. While the officer was en route, the officer observed R1 walking with a wheelchair approximately 1 mile from the facility. Due to the heat and distance, the officer offered R1 a ride back to the facility. (There was not a corresponding progress note in R1's medical record.) ~ A progress note, dated 7/30/24 at 8:01 PM, indicated a concerned citizen reported they saw R1 pushing a wheelchair far from the facility. The Assistant Director of Nursing (ADON) was notified. The note indicated staff would check for R1 at bedtime and notify the police if R1 was not there. ~ A progress note, dated 7/30/24 at 8:27 PM, indicated staff received a call from the police department that R1 was found in traffic outside the city. The writer informed the officer that R1 was R1's own person, signed R1's self out, and staff could not force R1 to return. The officer stated R1 did not want to return to the facility and the officer would bring R1 back to the city and call R1's emergency contact. A corresponding police report, dated 7/30/24 at 8:08 PM, indicated an officer was dispatched to an intersection of county highways approximately 1 mile from the facility. Dispatch stated R1 was alternating between pushing R1's wheelchair south on the highway and sitting in the wheelchair to take a break. A car with hazards lights was following R1 approximately 1.4 miles from the facility. The officer observed R1 on the side of the road. The citizen stated they called the police and tried to give R1 a ride back to the facility, but R1 refused. The officer identified R1 from previous contact. R1 stated R1 was going to a county psychiatric institution because the facility did not take care of R1. The officer informed R1 that walking on a county highway was a safety hazard. The officer called the facility, asked staff to pick up R1, and was told no. Staff stated there was nothing they could do because R1 was R1's own person. The officer contacted R1's emergency contact who stated they were in another city, recently had a medical issue, and couldn't drive. Approximately 15 minutes later, the officer convinced R1 to return to the facility. R1 whispered and some of R1's answers did not make sense. The officer requested an ambulance and R1 was transported to the hospital. ~ Progress notes, dated 7/30/24 10:45 PM and 11:30 PM, indicated the police found R1 in a traffic lane. R1 asked to be transported to a psychiatric institution or hospital. The police convinced R1 to go back to the facility, however, R1 refused to stay unless the facility gave R1 $25,000. R1 was transported to the hospital via ambulance at 9:00 PM and returned to the facility at 9:15 PM. R1 was treated for a urinary tract infection (UTI) with a one-time dose of antibiotics. ~ A Risk/Benefit Record, dated 8/1/24, indicated risk versus benefit education was provided by staff regarding R1 leaving the facility, notifying staff where R1 was going, and signing out. R1 was asked if staff could put a Wanderguard on R1's walker. R1 declined, but stated R1 would sign out and let staff know where R1 was going. ~ A progress note, dated 8/6/24 at 10:40 PM, indicated R1 returned to the facility at approximately 10:17 PM via police escort. R1 was found on the interstate near oncoming traffic. R1 had no apparent injuries, refused vital signs, refused medication, and stated R1's body works fine. A corresponding police report, dated 8/6/24 at 9:10 PM, indicated a welfare check was conducted for R1 at an intersection (one of the streets ran along a river) approximately 1.2 miles from the facility. The officer was not able to locate R1 upon arrival. Dispatch received a call a few moments later that R1 was on an interstate highway. The officer observed R1 walking on the fog line of an interstate highway off-ramp that was over 1.5 miles from the facility. R1 was self-propelling R1's wheelchair into head-on traffic and it was dark. The officer stated R1 was difficult to understand and R1's mental state was not 100%. R1 stated R1 was going to a county psychiatric institution and was taking back roads to get there. When the officer stated R1 was on a major highway and could not ride or walk on the side of the highway, R1 became argumentative and additional officers arrived. R1 was adamant about walking on the highway to get where R1 was going. R1 wanted to go anywhere but the facility and stated staff did not care if R1 came back. The officer spoke to R1 for less than twenty minutes, but determined R1's mental status was compromised. The officer brought R1 back to the facility. R1 apologized and stated R1 had a difficult time going back to the facility due to the way R1 was treated by staff. ~ A progress note, dated 8/18/24 at 3:10 PM, indicated R1 was R1's own person and signed out of the facility. An off-duty employee reported R1 was near a gas station and grocery store by a busy highway. Staff called the non-emergent dispatch line and asked police to check on R1. An officer reported that R1 stated R1 was taking a walk and would be back. The officer reinforced to R1 that R1 could not walk on the highway. A corresponding police report, dated 8/18/24 at 3:03 PM, indicated an officer was dispatched to an area near a grocery store where R1 was walking with a wheelchair and the officer located R1 near the store's driveway. Staff stated they were worried that R1 was trying to walk to a city that was 16 miles from the facility. R1 stated R1 wanted to go to the DMV in another city. The officer informed R1 that the DMV was closed and would reopen on 8/20/24. R1 stated R1 had a paper copy of R1's drivers license and wanted a card. The officer stated the officer didn't want to see R1 walk to another city and get hit by a car. R1 stated R1 would get food from the grocery store and go back to the facility. The officer called the facility and stated the officer would wait with R1 until staff picked up R1. Staff stated R1 was R1's own person and was free to walk around when R1 wanted. ~ A progress note, dated 8/18/24 at 5:50 PM, indicated a citizen called the facility and reported R1 was on a country road heading to the DMV in another city. The writer asked the citizen to stall and small talk with R1. The writer called the non-emergent dispatch line and updated them on R1's diagnosis of Huntington's disease, R1's location, and R1's description. The writer told dispatch they were concerned for R1's safety. A corresponding police report, dated 8/18/24 at 5:49 PM, indicated officer received a call that R1 was walking on a country road that was on the opposite side of an interstate highway from the facility. R1 left the facility several times recently attempting to go to other cities. R1's explanations for leaving the facility usually didn't make sense and R1 used a wheelchair to walk at a slow pace. Dispatch paged a county crisis worker and stated the officer was concerned that R1 would get lost in the dark and/or hit by a car. The crisis worker stated the facility was responsible for taking care of R1. The officer called the facility and asked staff to pick up R1. Approximately 30 minutes later, another officer responded to R1's location on the country road and transported R1 back to the facility. The officer reported R1 was walking down the middle of the road with no safety equipment to increase visibility for traffic. The report indicated there was continued neglect for R1's well-being as staff understood R1 was a potential threat to R1's safety but continued to let R1 leave unsupervised stating R1 was R1's own person. ~ Progress notes, dated 8/18/24 at 6:21 and 6:40 PM, indicated the writer spoke with an officer who contacted the county's Human Resources and stated there was nothing they could do because it was the facility's responsibility to make sure R1 returned. The writer contacted the Director of Nursing (DON) and made arrangements for staff to pick up R1 in the facility's van. A corresponding police report, dated 8/18/24 at 5:49 PM, indicated an officer was dispatched to a county road due to an elderly person wheeling northbound in the road in a wheelchair. R1 stated R1 was going nowhere in particular but did not want to be at the nursing home anymore. The officer transported R1 back to the facility. ~ A progress note, dated 8/20/24 at 12:28 AM, indicated R1 left the facility without signing out at approximately 8:10 PM. Non-emergency services were contacted at approximately 8:15 PM. R1 returned to the facility unescorted at approximately 8:20 PM. At approximately 8:25 PM, police arrived and stated the facility was not allowed to call the sheriff's department for this anymore. (There was no police report associated with the note.) ~ A progress note, dated 8/22/24 at 3:28 PM, indicated the writer spoke with R1 who stated R1 liked the facility and staff were nice and helpful, but R1 wanted to go to another city. R1 stated R1 liked to walk and needed 2 Diet Cokes per day but had no money. On 8/27/24 at 9:00 AM, Surveyor observed R1 in bed. On 8/27/24 at 9:12 AM, Surveyor interviewed Adult Protective Services Worker (APSW)-C via phone who verified APSW-C received information from the facility regarding guardianship for R1. APSW-C stated there was a residency concern regarding what county was responsible for R1. APSW-C stated the facility had not asked APSW-C for guidance on how to keep R1 safe while guardianship was in process. APSW-C stated APSW-C would have suggested the facility implement door monitors, walk with R1 outside for safety, encourage R1's return to the facility, and work with R1's physician on medication. On 8/27/24 at 9:45 AM, Surveyor interviewed R1 who was in bed. R1 expressed no concerns regarding staff treatment, stated I'm just getting older and stated R1 had no way to get anywhere because R1 had no money. R1 had a flat affect and provided short answers to Surveyor's questions. On 8/27/24 at 11:41 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated LPN-E worked at the facility for approximately nine months and could not recall if the facility did elopement drills. When asked about R1's elopement status, LPN-E stated R1 was R1's own person and could sign R1's self out. LPN-E stated when the police brought R1 back, staff checked R1 for injuries and reminded R1 to sign out and let staff know when R1 left. On 8/27/24 at 12:06 PM, Surveyor interviewed NHA-A who reviewed sign out forms for R1 since admission. NHA-A stated R1 starting exiting the facility in mid-June without signing out or letting staff know after R1's friend got sick and could no longer see R1 or take R1 out of the facility. When Surveyor indicated several sign-out entries by R1 contained illegible dates and times, NHA-A verified many of R1's entries were illegible. On 8/27/24 at 12:59 PM, Surveyor interviewed DON-B. When asked what the facility did to keep R1 safe, DON-B stated staff checked on R1 to see if R1 went where R1 said R1 was going and stated, If (R1) agrees to come with us, we'll give (R1) a ride back. DON-B stated staff spoke with the police department and agreed if R1 was gone for more than two hours, staff would call the police to check on R1. DON-B indicated there was no documentation of the conversation but stated the Fire Chief was there. DON-B stated in June of 2024, a Certified Nursing Assistant (CNA) was on a walk with R1 and called the facility because R1 wanted to go to another city. DON-B met the CNA and R1 at an elementary school approximately 0.5 miles from the facility. The CNA called the rescue squad and R1 was adamant with the Fire Chief that R1 wanted to walk to another city. R1 stated R1 knew the city was 45 miles away and it would take R1 a couple days to get there which was why R1 had water and a sweatshirt. DON-B verified walking on an interstate highway was a safety threat and stated, That's why we set up if gone for more than two hours to call police. DON-B verified a lot can happen in two hours and there were concerns for R1's safety. DON-B stated if R1 didn't sign out, staff were to re-educate R1 when R1 returned to the facility. On 8/27/24 at 4:16 PM, Surveyor interviewed Social Services Designee (SSD)-F who had been in SSD-F's current role for approximately one year. SSD-F stated a month or two ago, R1 stated R1 wanted to go to another city and reconnect with family. SSD-F set up a meeting with R1 and the Aging and Disability Resource Center (ADRC) who spoke to R1, but stated they were not done with their assessment yet and had 30 days. SSD-F stated the IDT talked about R1's safety daily but SSD-F could not recall specifics. SSD-F stated the facility felt guardianship should be pursued which is why R1's physician completed guardianship exam documents. SSD-F verified SSD-F did not document the discussion with R1 but should have. SSD-F stated, It (R1's safety) was always talked about, but the big thing was (R1) was (R1's) own person and able to sign (R1's) self out so everyone was not sure if we were allowed to keep (R1) here. I know a few times staff has brought (R1) back. The failure to supervise a resident with impaired safety awareness, impaired cognitive function, and a history of exiting the facility without signing out or letting staff know the resident was leaving created a reasonable likelihood for serious harm which lead to a finding of Immediate Jeopardy. The facility removed the jeopardy on 8/28/24 when it completed the following: 1. Educated residents who leave the facility independently to sign out with their location and when they will return. 2. Offered R1 transportation to locations not within walking distance. 3. Updated the Wander Communication Binder. 4. Initiated monthly elopement drills. 5. Reeducated staff on the elopement/wander policy, including care planning and identification of potential elopement risks.

Based on staff and resident interview and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R) (R1) of 3 sampled residents. On 10/2/23 at approximately 7:45 PM, R1 told Certified Nursing Assistant (CNA)-C that R2 had inappropriately touched R1 and had tried to get into R1's brief. CNA-C indicated the incident didn't happen and no action was taken. Approximately fifteen minutes later at 8:00 PM, staff heard R1 yell. Staff entered R1's closed door and observed R2, who was completely disrobed, on top of R1 and inappropriately touching R1. The facility's failure to supervise a resident who allegedly sexually abused another resident created a finding of immediate jeopardy that began on 10/2/23 at approximately 7:45 PM. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 10/19/23 at 3:15 PM. The immediate jeopardy was removed and corrected on 10/2/23 at 8:00 PM. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a copyright date of 2023, indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation . On 10/19/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (also known as stroke; a brain lesion in which a cluster of brain cells die when they don't get enough blood) which resulted in hemiplegia (paralysis/immobility of one side of the body) of left side, right hand amputation, anxiety disorder, and depression. R1's Minimum Data Set (MDS) assessment, dated 10/2/23, stated R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R1 was not cognitively impaired. On 10/19/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities) with behavior disturbance and macular degeneration (an eye condition which causes blurred or reduced central vision). R2's MDS assessment, dated 9/15/23, stated R2's BIMS score was 6 out of 15 which indicated R2 had severe cognitive impairment. R2's medical record indicated R2's Power of Attorney for Healthcare (POAHC) was responsible for R2's healthcare decisions. On 10/19/23, Surveyor reviewed the facility's investigation regarding an incident that occurred on 10/2/23 between R1 and R2. The investigation indicated: When writer (NHA-A) arrived on 10/2/23, NHA-A took a statement from R1 at 9:45 PM. R1 stated R2 entered R1's room and put a call light around R1's neck. While R2 put the call light around R1's neck, R2 tried to go into R1's brief. R1 activated the call light and attempted to holler for assistance. CNA-C entered the room. R1 told CNA-C that R2 put the call light around R1's neck and was going through R1's brief, but CNA-C said R2 did not do that because R2 was not in the room and the call light was not around R1's neck. According to R1, R2 came back into R1's room, undressed and got into bed with R1. R1 stated R2 crawled over R1's body, touched R1's chest, and said, I want to put your (genital) in my mouth .(R2's spouse's name), I have never felt like this in a long time and you are making me hot .and Give me a kiss. You are teasing me. During that time, R1 kicked the wall to get staffs' attention. R1 stated R2 briefly had R1's (genital) in R2's mouth, but not for long because R1 turned away from R2 to get away. When CNA-D entered the room, CNA-D observed R2's head on R1's stomach facing R1's private area. CNA-D stated R1's brief was intact, but R2 was pulling at it. CNA-D attempted to separate R2 from R1, but R2 was combative and said, Leave me alone, this is my (spouse), (spouse's name). CNA-D stepped out of R1's room and yelled for assistance. Licensed Practical Nurse (LPN)-E arrived, assisted R2 into R2's wheelchair, and covered R2 with a blanket. CNA-D and CNA-C assisted R2 back to R2's room where they helped dress R2 and put R2 to bed. The facility initiated 1:1 supervision for R2 at 8:30 PM on 10/2/23. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on 10/6/23 at 9:00 AM indicated the root cause was that R1's allegation was not taken seriously. Throughout the week, the Social Services Director met with R1. Progress notes indicated R1 felt safe, but wanted to speak with a telehealth psychiatric physician about the incident. NHA-A followed up with R1 on 10/6/23 to check on R1's well-being. R1 informed NHA-A that R1 was doing well, but had recurring thoughts about whether the police were going to arrest R1. NHA-A assured R1 that R1 did nothing wrong and that the police had already closed the case. On 10/19/23, Surveyor reviewed a documented interview with R1, dated 10/2/23, that contained the following: The first time (R2) came in, (R2) was in (R2's) wheelchair by the refrigerator, and I was looking for my call light. (R2) noticed I was looking for my call light and grabbed my call light and put it around my neck. While (R2) was giving me my call light, (R2) was also trying to go in my brief. I turned the call light on, and I was hollering for someone to come in. (CNA-C) came in and I told (CNA-C) that (R2) was trying to get in my brief and had the call light around my neck. (CNA-C) said, Nope (R2) did not do that. I responded by saying look at my brief. It is ripped I did not do that. (CNA-C) took (R2) out of the room and then (CNA-C) left. (R2) came into my room again and continued to put (R2's) hand in my brief. (R2) got out of the wheelchair and took all of (R2's) clothes off and started to rub my chest and said let me get in the bed with you. (R2) got in bed with me and was crawling all over me. (R2) sat on my legs and was crawling all over my body. (R2) said that I want to put your (genital) in my mouth. (R2) said take your pants off and then started to take my brief off. I told (R2) I did not have any pants on, and (R2) started taking the brief and throwing it on the floor. (R2) scratched my right arm and my right side with (R2's) rings. During this time, no one was answering the call light, so I attempted to kick the wall to see if someone would answer me. (R2) kept saying give me a kiss and kept saying stop teasing me. (R2) said, (R2's spouse's name), I never felt like this in a long time, and you are making me hot. (R2) then stated where is your other hand did you die too? I told (R2) I had a stroke and blood clots. I felt very uncomfortable the whole time. (R2) said if I don't get in your bed we are going across the hallway to other room across the hallway. Right before (CNA-D) came into the room, (R2) grabbed my (genital) and put a little bit of it into (R2's) mouth. I do not think it was for very long because I kept trying to turn to the wall side of the bed until (R2) was over there and then I turned to the other side of the bed. When (CNA-D) came in, (R2's) head was still over my crotch. (CNA-D) told the (R2) get out and do not go into the room. (CNA-D) assisted (R2) outside my room. On 10/19/23, Surveyor reviewed a documented interview with R1, dated 10/6/23, that contained the following: I will start with the first time (R2) came in here and came up beside my bed and I told (R2) I was looking for my call light. (R2) gave me the call light and then put it on the other side of the bed and then (R2) backed up with the cable in (R2's) wheelchair. The cable ended up around my neck and (R2) just kept backing up and it started to choke me, so I pushed the button. (CNA-C) came in and I told (CNA-C) (R2) had already started to pull at my brief and was choking me with my call light. (CNA-C) said, No (R2) did not. I then told (CNA-C) that I did not rip my brief or put the call light around my neck. After (CNA-C) left, (R2) came back into the room and said, I am going to get into the bed with you. (R2) then said, Give me a kiss. Don't you love me anymore? (R2) kept saying, Stop teasing me. I told (R2) this is a nursing home, and we are not allowed to do those kinds of things here. Then (R2) got undressed and got up in my bed and was rubbing my chest and climbing on me and going from one side of the bed to the other side of the bed. I hit the call light and started to holler. (R2) told me to be quiet so nobody would come in. I told (R2) I wanted someone to come in. Then (R2) said, You are making me hot (R2's spouse's name). (R2) also said, Where's your hand, did it die too? This freaked me out when (R2) asked about my arm because I did not know what (R2) meant by it. I got nervous and shaky and started kicking the wall. That is when (CNA-D) came in. (CNA-D) came in the door, and (R2) was ripping at my brief. (CNA-D) told (R2) to get out and not come into my room. On 10/19/23 at 10:40 AM, Surveyor interviewed R1 who declined to discuss the details of the incident. R1 indicated R2 had not been in R1's room since the incident and R1 felt safe at the facility. On 10/19/23, Surveyor reviewed an interview statement from CNA-C, signed and dated 10/4/23, that indicated: On 10/2/23 at approximately 7:45 PM, CNA-C provided care at the end of the 200 wing. When CNA-C exited the room, CNA-C noticed R1's call light was on, entered R1's room and asked what R1 needed. R1 said there was a little old lady in R1's room who pulled at R1's brief and put R1's call light by R1's neck. CNA-C noted R1's brief was intact and the top was folded over the way CNA-C left it, and R1's call light was draped over R1's shoulder and across R1's chest. CNA-C turned off the call light, went to the nurses' station, and reported what R1 said to Registered Nurse (RN)-F. CNA-C also told RN-F that CNA-C thought R1 made up the incident because there was no one in R1's room, R1's brief was intact, and the call light was draped across R1's chest. On 10/19/23 at 2:20 PM, Surveyor interviewed CNA-C who indicated CNA-C entered R1's room sometime before 8:00 PM on 10/2/23 in response to R1's call light. CNA-C indicated there was no one in R1's room at that time. CNA-C stated, Nothing (R1) said was visible. Call light was where I put it, not around (R1's) neck. Brief was as I put it (when CNA-C assisted R1 earlier in the shift). CNA-C indicated CNA-C looked at R1's brief and saw nothing wrong. When asked if CNA-C looked for R2, CNA-C stated, (R2) was kinda on a roll that night, roaming (R2's) hall and out front by TV. I believe I saw (R2) by TV area (when CNA-C left R1's room). CNA-C indicated RN-F was in the front office when CNA-C reported what R1 said and also told RN-F that CNA-C saw no observation that it was true. On 10/19/23, Surveyor reviewed an email from RN-F to Director of Nursing (DON)-B, dated 10/9/23, that contained RN-F's statement regarding the incident on 10/2/23 at approximately 8:00 PM and indicated: RN-F finished charting and went to find LPN-E to tell LPN-E goodbye. RN-F saw the medication cart on the 200 hall, called for LPN-E, and heard LPN-E tell RN-F from R1's room to hurry up and get in there. When RN-F reached R1's doorway and looked in, RN-F witnessed LPN-E assist R2, who was completely disrobed, and encourage R2 to sit down in R2's wheelchair. LPN-E told RN-F what was reported to LPN-E by CNA-D and what LPN-E saw when LPN-E entered R1's room. RN-F immediately went to the nurses' station and called DON-B to report the incident while LPN-E removed R2 from R1's room. On 10/20/23 at 11:11 AM, Surveyor interviewed RN-F via phone. RN-F indicated CNA-C did not tell RN-F about the first allegation from R1. RN-F indicated RN-F did not know anything occurred until RN-F was called into R1's room by LPN-E as stated in RN-F's email to DON-B. RN-F indicated if CNA-C would have told RN-F about the first allegation, RN-F would have immediately informed DON-B or NHA-A and made sure R2 stayed away from other residents. On 10/19/23, Surveyor reviewed R1's medical record which indicated R1 did not have a history of similar allegations against other residents. During the investigation, Surveyor noted the care plan interventions implemented to protect other residents from R2 were in place. The failure to supervise a resident following an allegation of sexual abuse by another resident led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 10/2/23 when it completed the following: 1. Put R2 on 1:1 supervision when out of room; Motion sensor on while in room to alert staff if R2 exits the room. 2. Moved R2 to a room further down the hallway from R1. 3. Offered telehealth psych services and a meeting with R1's physician. 4. Social Worker will meet with R1 once or twice daily. 5. Completed individual education with CNA-C and all staff education on abuse/reporting requirements.

Based on observation, interview, and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 5 Residents (R) (R13, R17, R32, R24, and R37) of 8 reviewed for nutrition concerns. R17 sustained a severe weight loss of 25.51% from 09/06/21 to 02/05/22. The facility did not implement Dietician-D's recommendations for monitoring nutritional status. Additionally, the facility did not have a systemic process to record, monitor, and assess R17's intake when R17 developed a stage IV pressure injury. R13 sustained a severe weight loss of 16.43% from 08/11/21 to 02/17/22. The facility did not properly assess, evaluate, and address R13's nutritional status. The facility did not have a systematic process to record, monitor, and assess R13's intake needs and implement corrective actions to prevent malnourishment for R13. The facility did not accurately assess, evaluate, and address the nutritional needs of R32. R32 sustained severe weight loss. R32's medical record dated 02/14/22 contained R32's most recent weight as 153.7 lbs which was a 25.39% weight loss in 5.5 months and 14.13% weight loss in one month. R24 sustained a severe 10.18% weight loss between 08/11/21 and 02/14/22. The facility did not provide timely assessments or interventions to ensure R24 maintained nutrition status or was maintaining R24's usual body weight. R37 sustained a severe weight loss of 5.56% between 01/04/22 and 02/14/22. The facility did not provide timely assessments or interventions to ensure R37 maintained nutrition status or was maintaining R37's usual body weight. Additionally, observations were made whereby R37 was not provided dining assistance when assistance was required per resident care plan. These failures created a finding of Immediate Jeopardy that began on 08/11/21. NHA (Nursing Home Administrator)-A was notified of the Immediate Jeopardy on 03/02/22 at 12:45 PM. The Immediate Jeopardy was removed on 03/03/22, however the deficient practice continues at a scope and severity of E (potential for more than minimal harm, pattern) as the facility continues to implement its action plan. Findings Include: The facility policy and procedure titled, Weight Assessment and Intervention, states; Weight Assessment: 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in residents medical record. 3. Any weight change of 5% or more since the last weight assessment a weight will be retaken for confirmation. If the weight is verified, nursing will notify the Dietician. 4. The Dietician will respond after notification. 5. The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. 7. If the weight is desirable, this will be documented and no change in the care plan will be necessary. 1. R17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 also has a Stage IV Pressure Injury on the left heel along with a Stage II and an Unstageable Pressure Injury to the left toes. R17's most recent MDS assessment, dated 02/01/22, indicates R17 requires one staff assist along with supervision during eating. R17 is [AGE] years old. R17's nutritional care plan, revised 07/11/19, states: I Have: Potential for Alteration in nutrition. Weight Fluctuation. Potential for Skin Problems and or breakdown. BECAUSE I: Adjustment to the nursing facility. Loss of husband - adjusted from that. Elder is on the go walks all over facility as she pleases. Dietary staff: Observe weights and intakes. Observe skin and labs. Honor food preferences. Offer all meals in the main dining room daily or room trays as requested. Offer set-up of meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids w/and in between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. RD review PRN. Offer alternate food items for all meals requested. I will have no significant weight changes per MDS criteria. Weight goal: BMI to WNL. Gradual weight loss expected with disease progression and overall decline. I will consume and tolerate >50% of meals, consistently to help promote healing with no s/s of dehydration or malnutrition. I will not experience negative effects related to dehydration/fluid deficit. Discuss nutritional approaches with IDT as needed. Review with nurse, prn for changes in medical status that may impact nutritional status. Obtain weight per facility protocol using same weight method for weight trend accuracy. Report significant weight changes to MD/NP and RD/DM. Offer and encourage NT fluids throughout the day to help maintain hydration status. Monitor for s/s of dehydration and report significant changes to MD/NP. Offer HS snack. Report acceptance. provide oral supplement per MD order I need my nurses to observe weights and intakes. Observe skin and labs. Observe for meal refusals and meal satisfaction. Encourage fluids w/ and in between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. I need my aides to obtain weekly weights. Observe skin report any skin redness to CN promptly. Offer set-up, assistance, cues and encouragement for all meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids w/ and in between meals daily. Offer meal time reminders as needed daily. Offer assistance to and from dining room as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. Record food intake. R17's most recent nutritional assessment, dated 01/27/22, indicates R17's intake is poor and states that R17's recommended weight range is 120-130lbs. R17 is noted to be underweight with significant and unplanned weight loss. R17's ideal daily fluid intake is 1000-1120 mLs. The assessment also states that R17 is currently at high nutritional risk secondary to multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .consume and tolerate >50% of meals .not experience negative effects related to dehydration/fluid deficit. Dietician-D recommends, monitor meal intakes, fluid intakes .house supplement with med pass for additional nutrition related to poor meal intakes. R17's most recent Nutritional History assessment, dated 06/18/21, does not indicate any resident preferences for food or beverages. Surveyor reviewed R17's weights for the past six months: - 09/06/21 - 121.9 lbs - 09/19/21 - 120.8 lbs - 10/15/21 - 121.4 lbs - 12/05/21 - 118 lbs - 01/15/22 - 97.7 lbs (loss of 20.78% in 1 month) - 02/05/22 - 90.8 lbs (loss of 7% in 1 month, loss of 34.25% in 6 months) Surveyor also reviewed R17's food and fluid intakes for the past 30 days: Meal Intake Documentation: 01/18/22: Missing breakfast and lunch, dinner 76-100% 01/19/22: Missing breakfast and lunch, dinner 51-75% 01/20/22: Missing breakfast and dinner, lunch 51-75% 01/21/22: Missing breakfast and lunch, dinner 76-50% 01/22/22: Missing breakfast, lunch 51-75%, dinner 0-25% 01/23/22: Missing breakfast and lunch, dinner 26-50% 01/24/22: Missing breakfast, lunch 51-76%, dinner 0-25% 01/25/22: Missing breakfast and lunch, dinner 51-75% 01/26/22: No intakes recorded 01/27/22: Missing breakfast, lunch 51-76% and dinner 26-50% 01/28/22: Missing breakfast and lunch, dinner 26-50% 01/29/22: Missing breakfast and dinner, lunch 26-50% 01/30/22: Missing breakfast and lunch, dinner 0-25% 01/31/22: Missing breakfast and lunch, dinner refused 02/01/22: Breakfast 26-50%, missing lunch, dinner 26-50% 02/02/22: No intakes recorded 02/03/22: Missing breakfast and lunch, dinner 51-75% 02/04/22: Missing breakfast, lunch 0-25%, dinner 26-50% 02/05/22: Breakfast 26-50%, missing lunch and dinner 02/06/22: No intakes recorded 02/07/22: Missing breakfast and lunch, dinner 26-50% 02/08/22: Missing breakfast and lunch, dinner 26-50% 02/09/22: Missing breakfast, lunch 26-50%, missing dinner 02/10/22: Missing breakfast and lunch, dinner 26-50% 02/11/22: No intakes recorded 02/12/22: Missing breakfast and lunch, dinner 26-50% 02/13/22: Missing breakfast and lunch, dinner 51-75% 02/14/22: Breakfast 26-50%, missing lunch and dinner 02/15/22: Missing breakfast and lunch, dinner 51-75% Facility staff failed to document R17's meal intake for 57 of 87 opportunities since 01/18/22. 18 of 30 meals documented fell below R13's goal of consuming >50% of meals. Facility staff failed to document R17's fluid intake for all of the last 30 days. On 02/16/22 at 3:36 P.M., R17's physician, MD-Q, was notified that R17 had, poor oral intake over the last day and resident only had 100cc intake. MD-Q notification did not include severe weight loss. On 02/16/22 at 3:30 P.M., Surveyor interviewed Dietician-D. Dietician-D verified that they were not notified of any significant weight loss for R17 or of R17's declining intakes. Dietician-D stated communication could always be better between Dietician-D and the facility staff. On 02/16/22 at 3:56 PM, Surveyor interviewed Director of Nursing (DON)-B who stated Dietician-D will send resident specific nutrition recommendations to DON-B, and will then forward to the MD and ask if MD wants to implement the recommendation, to send the order. DON-B stated that meal percent eaten should be documented for all meals. DON-B informed Surveyor that R17 was going to receive 500 mL subcutaneous gentle hydration per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 02/16/22 at 4:17 P.M., MD-Q responded to R17's update, recommending, 500 cc of gentle subcutaneous hydration, move to assisted dining room, and obtain CBC (complete blood count) and BMP (basic metabolic panel) tomorrow. On 02/17/22, R17 was admitted to the hospital for elevated white blood cell count. Physician notes from the hospital state R17 was admitted with, severe dehydration and [CONDITION(S)], and, appears malnourished with significant weight loss. R17's wound notes also indicate factors influencing wound healing including malnutrition, hypoprotein, and hypoalbuminemia with a BMI (Body Mass Index) of 17.34 kg/m^2 (healthy 18.5-24.9). R17's physician notes also indicate labs drawn on 11/30/21: protein 6.3 g/dL (normal 6-8.3 g/dL) and [MEDICATION(S)] 3.0 g/dL (normal 3.4-4 g/dL). 2. R13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's most recent Minimum Data Set (MDS) assessment, dated 11/21/21, indicates R13 requires one staff assist along with supervision during eating and extensive staff assistance for repositioning. R13 is [AGE] years old. R13's nutritional care plan, revised 3/15/21, states: I have: Potential for Alteration in Nutritional status, Weight Loss, Variable appetite and intakes. Interventions include: Enjoy my meals. Tolerate current diet plan. Remain independent with meals daily. Nutritional needs met. Comfortable with eating. Nutrition: Offered a General diet plan. Observe weights and intakes. Observe skin and labs. Honor food preferences. Offer all meals in room as preferred. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids Mw/ and between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. RD (Registered Dietician) review PRN. Offer alternate food items for all meals as requested. Nursing: Observe weights and intakes. Observe skin and labs. Observe for meal refusals and meal satisfaction. Encourage fluids w/ and between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. Offer ProSource 30cc BID, Vit D, Cholecalcif, 2.0 Supplement 240ml BID (twice daily), [MEDICATION(S)] for health and weight maintenance. Aides: Obtain weekly weights. Observe skin report any skin redness to CN (charge nurse) promptly. Offer set-up of meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids w/ and between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. Record food intakes. R13's most recent nutritional assessment was completed on 12/30/2020. It states that R13's recommended body weight range is 100-110 lbs and indicates that R13 is underweight. Recommended total daily fluids are 1000-1120 milliliters (mL). Goals include, consume and tolerate >50% of meals . with no s/s of dehydration of malnutrition with a recommendation for weekly weights. No further nutritional assessments were conducted in 2021 or 2022. On 02/15/22 at 12:12 P.M., Surveyor observed R13 sitting in R13's recliner with lunch tray on bedside table. R13's soup and beverages were still covered. No staff were in R13's room to provide adequate supervision or assistance. On 02/16/22 at 11:48 A.M., Surveyor observed R13 laying flat in bed with lunch tray on table next to bed. R13's coffee mug and water were still covered. No staff were in R13's room to provide adequate supervision or assistance. R13's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/29/20, R13 was started on ProSource Liquid Nutritional Supplement 30cc twice a day for supplement. On 03/15/21, R13 was started on [MEDICATION(S)] 7.5mg for weight loss. On 02/16/22, R13's order for Supplement 2.0 House Shake was adjusted to reflect smaller amounts more frequently, 4oz four times per day. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . All supplements and medications for nutrition were documented as administered. Surveyor reviewed R13's weights for the past year: - 02/22/21 - 91.3 lbs - 03/28/21 - 79.1 lbs (loss of 13.36% in 1 month) - 04/24/21 - 79.2 lbs - 05/30/21 - 77.8 lbs (loss of 14.79% in 3 months) - 06/30/21 - 80.8 lbs - 07/04/21 - 78 lbs - 08/11/21 - 80.8 lbs (loss of 11.5% in 6 months) - 09/15/21 - 77.1 lbs - 10/31/21 - 73.3 lbs - 11/26/21 - 69 lbs (loss of 17.1% in 3 months) - 12/09/21 - 71.5 lbs - 01/03/22 - 71.0 lbs - 02/17/22 - 69.4 lbs (loss of 16.43% in 6 months) R13, who was already below ideal body weight, had a 24% weight loss from February 2021 to February 2022. The facility did not complete weekly weights per R13's care plan. All documented weights fall below R13's recommended weight range of 100-110 lbs. Surveyor also reviewed R13's food and fluid intakes for the past 30 days: Meal Intake and Snack Documentation: 01/18/22: Missing breakfast and lunch, dinner 0-25% 01/19/22: Missing breakfast and lunch, dinner 26-50% 01/20/22: Missing breakfast, lunch and dinner 26-50% 01/21/22: Missing breakfast and lunch, dinner 26-50% 01/22/22: Breakfast refused, lunch 0-25%, dinner 26-50%, no snack offered 01/23/22: Missing breakfast and lunch, dinner 26-50% 01/24/22: Missing breakfast, lunch 0-25%, dinner 26-50% 01/25/22: Missing breakfast and lunch, dinner 0-25% 01/26/22: No intakes recorded, no snack offered 01/27/22: Missing breakfast, lunch and dinner 26-50% 01/28/22: Missing breakfast and lunch, dinner 0-25% 01/29/22: Missing breakfast and lunch, dinner 26-50%, no snack offered 01/30/22: Missing breakfast and lunch, dinner 0-25% 01/31/22: Missing breakfast and lunch, dinner 26-50% 02/01/22: Breakfast 0-25%, missing lunch, dinner 26-50% 02/02/22: No intakes recorded 02/03/22: Missing breakfast and lunch, dinner 0-25% 02/04/22: Missing breakfast, lunch 0-25%, dinner 26-50% 02/05/22: Breakfast 26-50%, missing lunch and dinner, no snack offered 02/06/22: No intakes recorded, no snack offered 02/07/22: Missing breakfast and lunch, dinner 26-50% 02/08/22: Missing breakfast and lunch, dinner 0-25% 02/09/22: Missing breakfast, lunch 26-50%, missing dinner 02/10/22: Missing breakfast and lunch, dinner 0-25% 02/11/22: No intakes recorded, no snack offered 02/12/22: Missing breakfast and lunch, dinner 0-25%, no snack offered 02/13/22: Missing breakfast and lunch, dinner 0-25%, no snack offered 02/14/22: No intakes recorded 02/15/22: Missing breakfast and lunch, dinner 0-25% 02/16/22: Missing breakfast and lunch, dinner 0-25%. Facility staff failed to document R13's meal intake for 60 of 89 opportunities since 01/18/22. All intakes fall below R13's goal of consuming >50% of meals. Fluid Intake Totals Documentation for 14 days: 02/02/22: No intake recorded 02/03/22: 120 mL 02/04/22: 860 mL 02/05/22: 460 mL 02/06/22: No intakes recorded 02/07/22: 120 mL 02/08/22: 120 mL 02/09/22: No intakes recorded 02/10/22: 240 mL 02/11/22: No intakes recorded 02/12/22: 240 mL 02/13/22: No intakes recorded 02/14/22: No intakes recorded 02/15/22: 120 mL 02/16/22: No intakes recorded Facility staff failed to document R13's fluid intake for 7 of 15 days. All documented daily total mL's fell below ideal intake of 1000-1120 mL's per day. On 02/16/22 at 3:30 P.M., Surveyor interviewed Dietician-D. Dietician-D stated that nutritional assessments are to be completed upon admission and annually thereafter unless the resident has a significant change in condition. Dietician-D verified that they were not notified of any severe weight loss for R13 or of R13's declining intakes and that R13 was overdue for a nutritional assessment. Dietician-D stated communication could always be better between Dietician-D and the facility staff. Dietician-D stated if the facility had notified Dietician-D of R13's significant weight loss, Dietician-D would perform an assessment which could trigger new dietary interventions. Dietician-D stated the expectation is Dietician-D and DM-F should know about weight loss in residents and that the MD or Nurse Practitioner (NP) should also be informed. On 02/16/22 at 3:56 PM, Surveyor interviewed Director of Nursing (DON)-B who stated Dietician-D will send resident specific nutrition recommendations to DON-B, and will then forward to the MD and ask if MD wants to implement the recommendation, to send the order. DON-B stated that meal percent eaten should be documented for all meals. DON-B also verified that R13 should not be left alone with a meal tray due to requiring supervision. DON-B stated that hospice services were going to be considered for R13 due to R13's increased fatigue and decreased intakes. On 02/16/22, Dietician-D conducted a nutrition assessment for R13. The assessment notes that R13 experienced unplanned significant weight loss and was underweight. It also states that R13 requires assistance and encouragement with meals and that R13 has had significant weight changes over the last year .weight loss due to COVID and decline in meal intakes. Resident is currently at high nutritional risk secondary to multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .weekly weights for 1 month for closer weight monitoring .continue with oral supplements but recommend smaller amounts more frequently. 3. R32 was admitted [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's most recent Basic Interview for Mental Status (BIMS) on 01/14/22 was 3 indicating severely impaired cognition. R32's BIMS at admission was 12 indicating moderately impaired cognition. R32 is [AGE] years old. On 02/15/22 at 11:16 AM, Surveyor interviewed R32's activated Healthcare Power of Attorney (HC-POA). HC-POA stated R32 did have weight loss and could see R32 appeared to look like R32 had weight loss when HC-POA visited. R32's medical record contained one Nutritional assessment dated [DATE] performed by Dietician-D. The Nutritional Assessment included: Diet Order: consistent carbohydrate, cardiac diet, regular consistency with thin liquids Food Allergy or Intolerance: NKFA (no known food allergies) Most recent height in inches: 68 Most recent weight: 220.2 lbs Recommended Weight Range: 140 lbs +/- 10% Adjusted Body Weight: 160 lbs Status: Obese Diuretic Therapy: Yes Planned Weight Changes: No Medications (Nutritional impact): [MEDICATION(S)] (diuretic), [MEDICATION(S)] ([CONDITION(S)]), potassium chloride, [MEDICATION(S)] (anti-diabetic), [MEDICATION(S)] (anti-diabetic.) Skin Breakdown: No Other/Comments: 05/12/21 Braden scale score (scale for predicting pressure injury risk) = 19, low risk [CONDITION(S)]: No Estimated Nutritional Needs: Adj wt (adjusted weight) 73 kg (kilograms) (160.6 lbs) .Total kcal 1679-1825 .Total Protein 58-73 .Total Fluids, Total mls (milliliters) 1679 - 1825 Nutritional Assessment/Recommendations: Assessment: Resident admitted to SNF (Skilled Nursing Facility) for therapies and skilled nursing care s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident [named individual] POA (Power of Attorney) however resident is able to make simple nutritional needs and preferences. Resident appears to be tolerating current diet well with no chewing or swallowing difficulties. Variable meal intakes noted, 25-75% with occasional acceptance of snacks. Dehydration score=3, low risk. Weight trend reviewed, stable since admission. BMI=33.4 obese. Resident is currently at moderate nutritional risk secondary to multiple medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Goals: Diet compliance. Consume and tolerate >50% of meals, consistently to help maintain good skin integrity with no s/s (signs and symptoms) of dehydration or malnutrition. No significant weight changes per MDS criteria however gradual weight loss desired which may be beneficial for multiple medical diagnoses. Plan/Recommendations: Monitor meal intake, labs prn (as needed), weight trend, skin integrity, diet compliance and plan of care. R32's medical record contained one Nutritional History dated 05/26/2021 by DM-F. The Nutritional History included: Diet Order: Offered Consist[[NAME]] Carb (carbohydrate) - Diabetic, Cardiac -Low Fat, Low chol (cholesterol) NAS (no added salt) Supplements: blank Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Most Recent Height: 66 Most Recent Weight: 281.6 Recommended weight range: blank Skin Breakdown: No Allergies: No Food intolerances: No Cultural, religious, ethnic food restrictions: No List Resident's daily food preferences (such as type of eggs, cereal, etc.): blank List the Resident's least favorite foods: blank List Resident's beverage choices for each meal: blank Will meals be eaten in dining room: No Is assistance required: No Does Resident have dental problems which will affect intake: No Are there difficulties chewing or swallowing: No Does Resident have a good appetite? Yes Have there been recent changes in intake/appetite? No Does Resident complain of changes in food taste? No Has there been a recent weight loss? No Has there been a recent weight gain? No Are there complaints of diarrhea or constipation? No Comments: Seeing ST (Speech Therapy) at this time. Observe weights and intakes. Observe skin and labs. Honor food preferences. Offer all meals in room at this time. Offer set-up of meals as needed daily. Observe for meal refusals and meal satisfaction. Offer snacks and fluids. Encourage fluids w/ (with) and between meals daily. Offer meal time reminders as needed daily. Observe appetite and eating abilities. Encourage nutrition as able as needed daily. RD (Registered Dietician) review PRN. Record food intakes. Offer alternate food items for all meals as requested. R32's Meal Ticket (contains a resident's diet and specific instructions) dated 02/16/2022 for breakfast stated: Dislikes: Egg; Likes: blank. R32's quarterly care conference dietary notes documented by DM-F included: 05/08/21 - Elder is seeing ST (Speech Therapy) at this time. Offered a Diabetic, Cardiac diet plan. Aware of meal times-no nutritional concerns at this time. Snacks between meals as she pleases daily. Makes needs known. 08/03/21 - Offered a General, Consistent Carb diet plan. Weight is slightly down since admission. Select preferences and patterns. Skin intact. Makes needs known. Aware of meal times - independent. Snacks between meals as (R32) pleases daily. 11/03/21 - Offered a Consistent Carb - Diabetic, Cardiac - Low Fat, Low Chol, NAS diet plan. (R32) has had a weight loss since admission. (R32) has fluid concerns nursing deals with. (R32) keeps to self in room as preferred. (R32) has lived a rather extensive wealthy lifestyle prior to admission with a daily routine that (R32) stuck to. Aware of meal times - feeds self, snacks between meals as (R32) pleases. Makes needs known. 12/27/21 - Offered [Vit] D3, Oyster supplement. Offered Consistent [Carb] - Diabetic, Cardiac - Low Fat, Low [Chol], NAS diet plan. Aware of meal times - independent. Snacks between meals as (R32) pleases daily. Small appetite and intakes. Weight loss fluctuation. Makes needs known. Select patterns and preferences and odd behaviors. R32's MDS contained the following weights: 05/12/21: 220 lbs. 06/01/21: 219 lbs. 09/01/21: 206 lbs. 11/24/21: 192 lbs. MDS section K0300 indicated a loss of 5% or more in the last month or loss of 10% or more in last 6 months as 2. Yes, not on physician-prescribed weight-loss regimen. 12/21/21: 185 lbs. 12/31/21: 179 lbs (6.77% weight loss in one month from 11/24/21.) Not identified in MDS as weight loss. 01/14/22: 179 lbs. Identified in MDS as weight loss. R32's medical record dated 02/14/2022 contained R32's most recent weight as 153.7 lbs which was a 25.39% weight loss in 5.5 months and 14.13% weight loss in one month. R32's medical record included weight summary and warnings as weights were documented in electronic medical records as indicated below: *05/05/2021, 220.2 lbs, Scale: Standing, no warnings *05/16/2021, 218.6 lbs, Scale: Standing, no warnings *06/04/2021, 218.2 lbs, Scale: Standing, no warnings *06/08/2021, 217.1 lbs, Scale: Standing, no warnings *07/09/2021, 218.0 lbs, Scale: Standing, no warnings *07/13/2021, 215.8 lbs, Scale: Standing, no warnings *08/11/2021, 206.0 lbs, Scale: Standing Warnings: -5% change [Comparison Weight 07/09/2021, 218 lbs, -5.5%, -12.0 lbs] *09/28/2021, 200.7 lbs, Scale: Standing Warnings: -7.5% change [Comparison Weight 07/09/2021, 218 lbs, -7.9%, -17.3 lbs] *10/14/2021, 198.3 lbs, Scale: Standing, no warnings *11/02/2021, 191.8 lbs, Scale: Standing Warnings: -10% change [Comparison Weight 05/16/2021, 218.6 lbs, -12.3%, -26.8 lbs] *12/09/2021, 185.3 lbs, Scale: Standing Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -7.7%, -15.4 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -15.0%, -32.7 lbs] *12/24/2021, 185.3 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -7.7%, -15.4 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -15.0%, -32.7 lbs] *12/25/2021, 185.5 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -7.6%, -15.2 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -14.9%, -32.5 lbs] *12/26/2021, 178.6 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 09/28/2021, 200.7 lbs, -11.0%, -22.1 lbs], -10% change [Comparison Weight 07/09/2021, 218 lbs, -18.1%, - 39.4 lbs] *01/01/2022, 179.4 lbs, Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 10/14/2021, 198.3 lbs, -9.5%, -18.9 lbs], -10% change [Comparison Weight 07/09/2021, 218.0 lbs, -17.7%, -38.6 lbs] *02/14/2022, 153.7 lbs Scale: Mechanical Lift Warnings: -7.5% change [Comparison Weight 12/09/2021, 185.3 lbs, -17.1%, -31.6 lbs], -10% change [Comparison Weight 09/28/2021, 200.7 lbs -23.4%, -47 lbs] R32 lost 66.5 lbs. in 10 months, a loss of 30%. R32's MDS Section G contained the following Activities of Daily Living (ADL) Assistance: 05/12/2021: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 0. Independent - no help or staff oversight at any time Support: 1. Setup help only. 09/01/2021: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 1. Supervision - oversight, encouragement or cueing Support:1. Setup help only. 11/24/2021: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 0. Independent - no help or staff oversight at any time Support:1. Setup help only. 12/31/21: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 0. Independent - no help or staff oversight at any time Support:1. Setup help only. 01/14/2022: H. Eating - how resident eats and drinks, regardless of skill . Self-Performance: 1. Supervision - oversight, encouragement or cueing Support: 2. One person physical assist. On 02/16/22 at 9:32 AM, Surveyor interviewed Dietary Manager (DM)-F regarding R32's weight loss. DM-F stated it was challenging meeting everyone's individual needs compared to when group dining was allowed to happen. DM-F stated the nutritional intervention in place for R32 was nurses provided house shake to R32 as a nutritional supplement. DM-F stated R32 had a lot of behaviors that could make it difficult to eat. DM-F stated R32 can feed self and at times will allow staff to assist with eating. DM-F stated R32 wants to be independent, but that is not in R32's best interest. DM-F stated the interventions in place are to provide the house shake to R32 and assist if R32 allows. Review of R32's medical record did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's dietary care plan included: Focus: I have an alteration in my nutritional status secondary to multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) 05/06/21 revised 02/16/22. Goal: I will be compliant with therapeutic diet as recommended by MD/NP (Medical Doctor/Nurse Practitioner.) I will consume and tolerate >50% of meals, consistently to help maintain good skin integrity with no s/s (signs and symptoms) of dehydration or malnutrition. I will have no significant weight chan

Based on observation, record review, and staff interview, the facility did not ensure each resident received necessary treatment to prevent pressure injuries from developing for 2 Residents (R) (R8 and R17) of 4 sampled residents reviewed for pressure injuries. Facility staff did not properly assess R17's deep tissue injury that developed around 12/15/21 until 01/26/22. R17's care plan was not updated to include current pressure injuries and interventions and the treatment record shows missing treatments. On 02/21/21, R17's heel ulcer was mechanically debrided into a Stage IV and was found to be infected. Findings include: The facility policy titled, Pressure Ulcers/Skin Breakdown revised April 2018, states: The nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments, including support surfaces; and all active diagnoses. According to Clinical insights: Understanding the link between nutrition and pressure ulcer prevention (2015,) Nutritional status plays a central role in the process of wound healing. Malnutrition accompanies a poor outcome and brings about higher morbidity and mortality. Malnutrition should be recognized rapidly and treated accordingly in all patients suffering from pressure ulcers. Malnutrition impedes pressure ulcer healing. Unplanned weight loss - which is defined as 5% weight loss within 1 month or 10% within 6 months by the minimum data set - is a major risk factor for malnutrition and pressure ulcer development. 1. R17 was readmitted to the facility from the hospital on 12/02/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's most recent Minimum Data Set (MDS) assessment, dated 12/09/21, indicates that R17's Brief Interview for Mental Status (BIMS) score was a 4, indicating severe impairment. R17's MDS also states that R17 requires extensive assistance for repositioning, transferring, dressing, and hygiene and that R17 had limited range of motion in one lower extremity. R17's MDS indicates a risk for pressure injuries with no current open areas. R17's care plan, revised 12/24/21 states, I have the potential for pressure ulcer development and skin impairment related to decreased immobility and incontinence . Goals include, I will have intact skin .through review date with the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate me/family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements .good nutrition and frequent repositioning. Monitor nutritional status. Serve diet as ordered, monitor intake and record. R17's care plan did not reflect R17's current pressure injuries or treatments and did not include R17's pressure-reducing boot. R17's medical record showed multiple missing meal intakes as well as no monitoring for R17's fluids. (See F692) R17's medical record contained the following Bath/Shower forms and skin assessments since R17's readmission from 12/02/21 to 02/17/21: - 12/14/21: no skin concerns noted, indicates, between toes washed and dried - 12/24/21: no skin concerns noted, indicates, between toes washed and dried A weekly skin check was also done on 12/24/21 with no concerns noted. - 12/30/21: no skin concerns noted, indicates, between toes washed and dried - 01/12/22: no skin concerns noted - 01/19/22: no skin concerns noted, indicates, between toes washed and dried R17's medical record contained the following Weekly Wound Assessments: ~ 01/26/22: - Left heel wound, nonhealing hematoma, 5cm x 5cm x 0.1cm, 100% thick hard black non-viable tissue, moderate amount of seroussanguinous (blood-tinged) exudate (drainage), no odor, pain associated with wound, [MEDICATION(S)] TID (three times per day), Resident had a traumatic injury to her left heel from hitting it on her wheelchair foot pedal. It has since deteriorated into an open wound. Wound dressing is dakins wet to dry to be changed daily. Will continue to monitor. - Left toes, pressure, 0.3cm x .03cm x 0.1cm, unstageable, 50% granulation (healing tissue) and 50% slough (yellow/gray non viable tissue), moderate amount of seroussanguinous drainage, no odor, pain associated with wound, [MEDICATION(S)] TID, Resident was noted to have an unstageable pressure injury between [R17's] 4 and 5th toes on [R17's] left foot. Wound dressing is [MEDICATION(S)] blue classic to the wound bed to be changed QOD (every other day). Will continue to monitor. - Left medial foot, pressure, 0.2cm x 0.2cm x 0.1 cm, unstageable, 100% slough, moderate amount of seroussanguinous drainage, no odor, pain associated with wound, [MEDICATION(S)] TID, Resident was noted to have an unstageable pressure injury on the medial aspect of her left foot. Wound dressing is [MEDICATION(S)] to the wound bed, covered with foam dressing to be changed daily. Will continue to monitor. ~ 02/02/22: - Left heel wound, nonhealing hematoma, 5cm x 5cm x 0.1cm, 100% thick hard black non-viable tissue, moderate amount of seroussanguinous (blood-tinged) exudate (drainage), no odor, pain associated with wound, [MEDICATION(S)] TID (three times per day), Resident had a traumatic injury to her left heel from hitting it on her wheelchair foot pedal. It has since deteriorated into an open wound. Wound dressing is dakins wet to dry to be changed daily. Will continue to monitor. - Left toes, pressure, 0.3cm x .03cm x 0.1cm, unstageable, 50% granulation (healing tissue) and 50% slough (yellow/gray non viable tissue), moderate amount of seroussanguinous drainage, no odor, pain associated with wound, [MEDICATION(S)] TID, Resident was noted to have an unstageable pressure injury between [R17's] 4 and 5th toes on [R17's] left foot. Wound dressing is [MEDICATION(S)] blue classic to the wound bed to be changed QOD (every other day). Will continue to monitor. - Left medial foot, pressure, 0.2cm x 0.2cm x 0.1 cm, unstageable, 100% slough, moderate amount of seroussanguinous drainage, no odor, pain associated with wound, [MEDICATION(S)] TID, Resident was noted to have an unstageable pressure injury on the medial aspect of her left foot. Wound dressing is [MEDICATION(S)] to the wound bed, covered with foam dressing to be changed daily. Will continue to monitor. ~ 02/09/22: - Left heel wound, nonhealing hematoma, 5cm x 5cm x 0.1cm, 100% thick hard black non-viable tissue, moderate amount of seroussanguinous (blood-tinged) exudate (drainage), no odor, pain associated with wound, [MEDICATION(S)] TID (three times per day), Resident had traumatic injury to her left heel from hitting it on her wheelchair foot pedal. It has since deteriorated into an open wound. Wound has not had any significant progress since last checked. Wound treatment is going to be [MEDICATION(S)] to the wound bed and covered with foam dressing to be changed BID (twice a day) If wound continues to not make progress, wound clinic referral will be requested. Will continue to monitor. - Left toes, pressure, 0.3cm x .03cm x 0.1cm, unstageable, 50% granulation (healing tissue) and 50% slough (yellow/gray non viable tissue), moderate amount of seroussanguinous drainage, no odor, pain associated with wound, [MEDICATION(S)] TID, Resident was noted to have an unstageable pressure injury between [R17's] 4 and 5th toes on [R17's] left foot. Wound dressing is [MEDICATION(S)] blue classic to the wound bed to be changed QOD (every other day). Will continue to monitor. - Left medial foot, pressure, 0.2cm x 0.2cm x 0.1 cm, unstageable, 100% slough, moderate amount of seroussanguinous drainage, no odor, pain associated with wound, [MEDICATION(S)] TID, Resident was noted to have an unstageable pressure injury on the medial aspect of her left foot. Wound dressing is [MEDICATION(S)] to the wound bed, covered with foam dressing to be changed daily. Will continue to monitor. R17's treatment record shows the following orders and administrations: 01/24/22 - 01/31/22: - Cleanse between 4th and 5th digits in left foot, insert moistened [MEDICATION(S)] classic, wrap in [MEDICATION(S)], one time a day every other day. (Missing 1 of 4 opportunities) - Cleanse DTI (deep tissue injury) to left heel, apply wet-to-dry dressing, cover with ABD, wrap with kerlix one time a day. (Missing 2 of 8 opportunities) - Cleanse wound to medial left foot, apply medi-honey, cover with foam boarder dressing one time a day. (Missing 2 of 8 opportunities) 02/01/22 - 02/17/22: - Cleanse between 4th and 5th digits in left foot, insert moistened [MEDICATION(S)] classic, wrap in [MEDICATION(S)], one time a day every other day. - Cleanse DTI (deep tissue injury) to left heel, apply wet-to-dry dressing, cover with ABD, wrap with kerlix BID. (Missing 4 of 14 opportunities) Order changed on 2/9 to apply [MEDICATION(S)] to the wound (Missing 3 of 16 opportunities) - Cleanse wound to medial left foot, apply medi-honey, cover with foam boarder dressing one time a day. (Missing 1 of 17 opportunities) Facility staff failed to document R17's meal intake for 57 of 87 opportunities since 01/18/22. 18 of 57 meals documented fall below R17's goal of consuming >50% of meals. Facility staff failed to document R17's fluid intake for all of the last 30 days. R17's medical record contained the following progress notes: - 01/22/2022 at 4:55 P.M. a nurse's note states: Writer was called to resident's room to assist with assessing DTI on resident's left heel. It was determined that the DTI had deteriorated and is now an open wound. It was also noted that resident had pressure injuries to the medial aspect of her left foot and on the lateral aspect of her 4th toe and the medial aspect of her 5th toe. Heel dressing with be wet to dry changed daily. Medial foot dressing will honey and bordered foam dressing changed daily. Toe injuries will be [MEDICATION(S)] blue classic changed EOD. Will continue to monitor. - 01/29/2022 at 1:46 P.M. Nurses Note states MD-O referral to wound care [named clinic]. - 02/11/22, R17's physician notes Significant DTI to the left heel with significant eschar An order was added by the physician stating, If no word from [wound clinic] by Tues 2/15 please call. - 02/12/22 Nurses's Note: Wound dressing to Medial left foot, [MEDICATION(S)] to the woundbed, covered with foam dressing changed daily. Slight odor and slight amount of yellow drainage from medial wound and heel wound. Resident cooperative but had discomfort during dressing change. Will continue to monitor. - 02/13/2022 Nurse's Note: Wound dressing to Medial left foot, [MEDICATION(S)] to the wound bed, covered with foam dressing changed daily. Foul odor and moderate amount of yellow/green drainage from medial wound and heel wound. Resident was not cooperative during dressing change. - 02/14/2022 Nurse's Note: Wound dressing to Medial left foot, [MEDICATION(S)] to the wound bed, covered with foam dressing changed daily. Foul odor and moderate amount of sero/sang drainage from medial wound and heel wound. Resident was not cooperative during dressing change - 02/17/2022 Note Text: Wound dressing to the left foot, [MEDICATION(S)] was applied covered with foam dressing change daily. Slight odor and slight amount of drainage from heel wound. Will continue to monitor On 02/15/22 at 9:45 A.M., Surveyor interviewed R17's Power of Attorney (POA), who stated concerns about dressing changes being missed for R17's wounds. On 02/16/22 at 10:02 A.M., Surveyor observed Registered Nurse (RN)-E provide wound care to R17. RN-E verified that R17, hit [R17's] foot on the wheelchair pedal around 12/15/21. RN-E stated that a pressure-reducing boot was started at that time. RN-E further stated that R17 had no pressure-relieving interventions for R17's left foot in place prior to the development of the deep tissue injury on R17's left heel in December 2021. RN-E agreed that R17 had, some limited range of motion in the left lower extremity due to the femur fracture. RN-E verified that there were no assessments of R17's DTI from when it developed in December until 01/26/22. RN-E shared that R17's wound clinic appointment was scheduled for 02/23/22. On 02/16/22 at 1:14 P.M., Surveyor interviewed Certified Nursing Assistant (CNA)-P, who verified that R17's heel boot was not started until after the bruise started on R17's heel. CNA-N also said that R17 was in bed for a while after returning from the hospital post-femur fracture. On 02/17/22 at 11:11 A.M., Surveyor interviewed the Director of Nursing (DON)-B, who agreed that R17 would have been at high risk for developing pressure injuries to the left leg and foot due to impaired mobility and pain following the fracture along with the history of DVT in left leg. DON-B verified that there were no assessments of R17's DTI prior to 01/26/22, even though it developed around 12/15/21. On 02/17/22, R17 was admitted to the hospital for elevated white blood cell count. Physician notes from the hospital state, appears malnourished with significant weight loss. R17's heel injury was cultured, which showed growth of Proteus Mirabilis (bacterium). On 02/21/22, R17's heel wound was mechanically debrided (removal of dead tissues) to reveal a stage IV pressure injury measuring 5.3cm x 6.1cm x 1.5 cm. R17's left medial foot wound was assessed to be a stage III injury measuring 0.8cm x .5cm x 0.2cm. R17 received antibiotics while in the hospital. On 02/24/22 at 5:04 P.M., Surveyor interviewed MD-Q, who verified that they were first informed of R17's wounds on 01/23/22 after the DTI had opened up and observed the wound on 02/11/22. MD-Q was not updated on the increase in foul odor and yellow drainage (signs of infection) in R17's wounds. MD-Q stated that they would expect the facility to notify of signs and symptoms of infection and, if properly notified, MD-Q would have assessed the wound and ordered labs and cultures to direct treatment. MD-Q also verified that R17's DTI to the left heel could have been prevented if pressure-relieving interventions had been put in place when R17 was readmitted to the hospital.

Based on staff interviews and record review, the facility did not immediately consult with the resident's physician for 1 (R (Resident) 1) of 4 sampled residents when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). R1 presented with nausea, vomiting and loose stools on 1/5/19 which persisted until 1/9/19. During this time period, the resident refused most meals; did not meet the daily fluid intake requirements to maintain hydration; had increased weakness; and was refusing most medications to include potassium supplements. The facility did not consult with the resident's physician regarding the change in the resident's physical status. During R1's physician's routine monthly rounds on the evening of 1/9/19, R1 was noted with acute GE (Gastroenteritis); acute de-conditioning; dehydration and increase in tremors. R1's physician ordered the resident be transported to the hospital for evaluation and was diagnosed with [REDACTED]. Findings include: The facility's policy entitled, Resident Hydration and Prevention of Dehydration dated (MONTH) 2011 indicates, .If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the plan of care. Physicians will be informed. The Dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Review of the Dehydration and Fluid Maintenance Clinical Resource guide, utilized by the facility and dated 2001, indicates to determine if alterations in hydration status represent a significant change of condition such that a major decline in status has occurred. Inform and consult with the medical provider as needed if interventions are not effective. The facility's Change in a Resident's Condition or Status policy dated December, (YEAR) indicates the nurse shall promptly notify the resident's attending Physician of changes in the resident's medical/mental condition and/or status. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without interventions by staff; impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision to the care plan. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the residents medical/mental condition or status. R1's medical record was reviewed and it included documentation that the resident's [DIAGNOSES REDACTED]. The resident was own decision maker. R1's current medication regime included potassium 10 meq (miliequivalents) twice daily. A Dietary note dated 12/21/18, documented R1 was 59 inches tall and weighed 153 pounds with daily fluid requirements calculated to be 2450 ml/day, had a fair to good appetite and was receiving 3 different fluid nutritional supplements, 2 of which are given and charted by a licensed nurse. The additional supplement was served with each meal tray. One of the supplements was ordered daily, and 2 were ordered three times daily. R1's last documented weight was 159.5 pounds on 1/1/19. Review of R1's medical record and CNA (Certified Nursing Assistant) meal intake record included the following entries: ~ 1/5/19, Medication held due to nausea, vomiting, loose stools on evening shift. Refused night pills and supplements. Afebrile (without fever). Pulse 86, BP (Blood Pressures) 100/70. Refused lunch and supper food and fluids. Given medication for nausea. Refused evening medications and bed time medications. ~ 1/5/19, No night shift entry. The medical record did not include documentation that R1's physician had been notified of the change in the resident's health status. ~ 1/6/19, Evening shift. Resident started having soft loose mushy stools, highly colored but watery x 2 yesterday afternoon and 2 extra large soft mush non-formed stools, mustard colored, sour smelling. Abdomen soft with active bowel sounds. Complained of nausea briefly yesterday but then resolved. Continued to have 3 more large loose stools on PM and N[NAME] shift and placed on contact precautions. This morning had large soft mushy stool and extra large mush stool on PM shift. No issues with nausea reported today. Afebrile, pulse 78. The medical record did not include documentation that the resident's BP had been assessed. Documentation included that the resident refused breakfast, drank 120 ml. Refused all food and fluids for lunch, ate 25% of evening meal and drank 240 ml. Accepted all supplements. Refused some evening and bed time medications. The medical record did not include documentation that R1's physician was notified of the change in the resident's health status. ~ 1/6/19, No night shift entry. The medical record did not include documentation that R1's physician had been notified of the change in the resident's health status. ~ 1/7/19, Day shift. Refused AM medications stated, don't feel well. Vital signs of afebrile, pulse 60, (no BP recorded). ~ 1/7/19, PM shift. Afebrile, pulse 85, BP 122/75. Refused supplements and medications stating, can't keep anything down. Given medication for nausea. Medication effective. PM intake 480 ml. Incontinent x 1. Tolerating water. No emesis. The resident had refused 6 of 7 supplements for the day. The resident had refused all three meals and all fluids served with meals. ~ 1/7/19, No night shift entry. The medical record did not include documentation that R1's physician had been notified of the change in the resident's health status to include R1 refusing all medications on 1/7/19. On 1/7/19, R1's family member contacted a non attending physician indicating (R1) drinking very little and dehydration suspected (e.g., no urine >12 hours, very dry mouth, very light headed). The triage nurse instructed the resident's family member to send the resident to the emergency room , but the resident refused. This correspondence was given to the Surveyor by DON (Director of Nursing)-A and stated, I just found this in (R1's) chart. I didn't know it was there. ~ 1/8/19 at 1:14 AM, Resident remains on contact precautions for noted loose stools and emesis over previous 24-28 hours. No emesis noted this night. Reported nausea to be much improved. Remains afebrile. Has been able to tolerate water this night without difficulty. Will continue to observe as needed. ~ 1/8/19, Intake PM. 480 ml. Incontinent x 1. Intake for past 24 hours is 600 ml. BP 122/75. Intake for nights 120 ml. Incontinent x 2. Refused medications. Day intake 360 ml Incontinent x 1. Afebrile, pulse 64, BP 110/71. No loose stools on nights. The resident had eaten 50% of breakfast and taken in 240 ml of fluids during the breakfast meal and refused both lunch and supper meals and fluids served with meals. The resident refused all dietary fluid nutritional supplements on 1/8/19 and had refused all medications on 1/8/19. The medical record did not include documentation that R1's physician had been notified of the change in the resident's health status to include R1 refusing medications, meals and oral intake on 1/8/19. ~ 1/9/18 at 11:2 AM, Had 2 loose golden stools, slightly more substance. Appetite poor today. Declined med's today, denies nausea when asked but later complained of some nausea. No emesis. More with drawn today and keeping eyes closed. ~ 1/9/19 at 4:27 PM, Had 2 more loose golden colored stools, slightly more substance. Appetite poor today. Abdomen soft with active bowel sounds, drinking water at times. Poor food intake. Lungs sound clear anteriority. Verbalizes, not feeling right but unable to explain what is feeling. Afebrile. Will have MD assess on round this evening. Will continue to observe. Intake days 480 ml. Incontinent x 3. BP 110/70. The resident had refused all supplements, 99% of medications, and had refused all three meals and fluids served with meals on 1/9/19 with the exception of taking in 240 ml at breakfast. The medical record did not include documentation that R1's physician had been notified of the change in the resident's health status to include R1 refusing medications and intake on 1/9/19. On 1/9/19 at approximately 6:30 PM, R1's physician, MD (Medical Doctor)-C, made routine rounds on residents at the nursing facility and examined R1. MD-C's documentation indicated R1 had diarrhea, decreased appetite and weakness with dry oral mucosa and decreased level of alertness. MD-C indicated R1 had acute GE with acute de-conditioning, dehydration and increased tremors. MD-C sent R1 to the emergency room for evaluation. The emergency room provider report dated 1/9/19, documented R1 opens eyes to command but follows no additional commands. Laboratory findings included an increase in the resident's creatinine level to 1.28, previous level of 0.97 on 5/31/18 and a significant low potassium level of 2.3. (Potassium level of less than 2.5 is considered to be very serious and can cause abnormal heart rhythms, even when slightly low if the patient already has a heart disorder). R1 was admitted to the hospital for a 3 day stay and received IV fluids and IV potassium. The hospital history and physical, dated 1/9/19, documented R1 had severe [DIAGNOSES REDACTED] (low potassium) due to gastrointestinal loss, possible [MEDICAL CONDITION] gastroenteritis and dehydration. The document indicated, Resident has a significant electrolyte imbalance with a potassium of only 2.3. This is most likely a result of vomiting and diarrhea that are probably from an acute GE. The hospital discharge summary, dated 1/12/19, documented The patient (R1) was notably more alert and active thought to be at baseline prior to discharge. R1's stool culture results were positive for Norovirus. On 1/22/19 at 10:45 AM, the Surveyor interviewed DON-A regarding R1. DON-A verified R1's physician had not been notified of the resident's significant change in status during the time frame of 1/5/19 to 1/9/19. DON-A stated, I came in later in the day on 1/9/19 and the day nurse (R (Registered Nurse)-B) told me (R1) was asking to see the doctor. When the doctor came in for routine rounds at about 6:30 PM that evening, I asked him (MD-C) to see (R1) first. Staff should be notifying the physician when residents are having health issues that don't improve after 48 hours. On 1/22/19 at 11:00 AM, the Surveyor interviewed R1's attending physician, MD-C via the telephone regarding R1. MD-C stated looked through all faxes and correspondence from the facility between 1/5/19 and 1/9/19 and verified had not been made aware of R1's significant change in condition at any time during that period of time. MD-C stated, If (R1) had no improvement in symptoms and significant change, I would have expected the staff to contact me to notify me and update me after 24-48 hours if things had not improved. I saw (R1) on routine rounds on the evening of 1/9/19. (R1's) vitals were not stable and (R1) was not communicating with me as usual and I sent (R1) to the emergency room for evaluation of suspected acute GE and dehydration. On 1/22/19 at 12:15 PM, the Surveyor interviewed RN-B regarding R1. RN-B stated, The doctor was making routine rounds late afternoon on 1/9/19. I told (R1) that the doctor would be here in a couple of hours. That was about 4:00 PM and the resident was asking to see the doctor . RN-B verified had not notified R1's physician when the resident had presented with and continued with a significant change in status and stated, I knew that (R1's) doctor was coming in the evening of 1/9/19 so I didn't notify the doctor.

Based on record review and staff interviews, the facility did not ensure 1 (R (Resident) 1) of 1 sampled residents had sufficient fluid intake to maintain proper hydration and health. R1 presented with nausea, vomiting, loose stools and weakness on 1/5/19 which persisted through 1/9/19 and was placed in isolation due to these symptoms of GE (Gastroenteritis). R1 refused all food and fluids for 13 of 15 meals during that time frame, refused most medications and refused 17 out of 25 prescribed fluid nutritional supplements given by licensed staff. Facility staff did not complete a thorough hydration assessment, did not establish accurate intake and output records, did not develop a care plan relating to ensuring adequate hydration during an acute illness, did not consult with the Dietician regarding the resident's poor appetite and poor oral intake of fluids and did not recognize the decline of R1's hydration status. The evening of 1/9/19, during routine rounds by R1's attending physician, R1 was assessed with [REDACTED]. R1 was transported to the hospital and diagnosed with [REDACTED]. Findings include: The facility's policy entitled, Resident Hydration and Prevention of Dehydration dated (MONTH) 2011 indicates, Minimum fluid needs will be calculated and documented with significant change assessments using current standards of practice. Nurse Aides will document intake in the medical records. Aides will report intake of less than 1200 ml(millimeters)/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the plan of care. Physicians will be informed. The Dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Nursing will monitor and document fluid intake and the Dietician will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. Review of the Dehydration and Fluid Maintenance Clinical Resource guide, utilized by the facility and dated 2001 indicates to gather complete and accurate information about the resident's fluid status for dehydration. Review existing [DIAGNOSES REDACTED]. Observe for presence of any signs and symptoms that may be associated with dehydration to include recent rapid weight loss, dry eyes/mouth, decreased fluid intake or increased output, altered mental status, postural [MEDICAL CONDITION], pulse greater than 100 beats/minute, systolic blood pressure less than 100, dizziness, concentrated/small amounts of urine, swallowing problems, fever, vomiting, lethargy, diarrhea, weakness, confusion and change in ability to carry out activities of daily living. Pull together all pieces of information gathered about the resident's fluid status and risk for dehydration; analyze that information to determine care needs based on risk, cause or contributing factors. Develop care plan goals and approaches that specifically address the resident's fluid status and risk for dehydration, with a focus on maintaining or improving the resident's fluid status and intake. Provide interventions promptly. Evaluate the effect of the interventions. Determine if alterations in hydration status represent a significant change of condition such that a major decline in status has occurred. Inform and consult with the medical provider as needed if interventions are not effective. R1's medical record was reviewed and included documentation that the resident's [DIAGNOSES REDACTED]. The resident was own decision maker. R1's current medication regime included potassium 10 meq (miliequivalents) twice daily. A Dietary note dated 12/21/18 documented R1 was 59 inches tall and weighed 153 pounds with daily fluid requirements calculated to be 2450 ml/day, had a fair to good appetite and was receiving 3 different fluid nutritional supplements, 2 of which are given and charted by a licensed nurse. The additional supplement was served with each meal tray. One of the supplements was ordered daily, and 2 were ordered three times daily. R1's last documented weight was 159.5 pounds on 1/1/19. R1's current care plan did not include interventions relating to the potential for dehydration due to nausea, vomiting, loose stools and poor oral intake of food and fluids or the need for staff to complete a hydration assessment and 24 hour fluid intake calculation and output. Review of R1's medical record and CNA (Certified Nursing Assistant) meal intake record included the following entries: ~ 1/5/19, Medication held due to nausea, vomiting, loose stools on evening shift. Refused night pills and supplements. Afebrile (without fever). Pulse 86, BP (Blood Pressures) 100/70. Refused lunch and supper food and fluids. Given medication for nausea. Refused evening medications and bed time medications. ~ 1/5/19, No night shift entry. The medical record did not include documentation that staff completed a hydration assessment for R1 and did not complete a 24 hour fluid intake calculation. ~ 1/6/19, Evening shift. Resident started having soft loose mushy stools, highly colored but watery x 2 yesterday afternoon and 2 extra large soft mush non-formed stools, mustard colored, sour smelling. Abdomen soft with active bowel sounds. Complained of nausea briefly yesterday but then resolved. Continued to have 3 more large loose stools on PM and N[NAME] shift and placed on contact precautions. This morning had large soft mushy stool and extra large mush stool on PM shift. No issues with nausea reported today. Afebrile, pulse 78. The medical record did not include documentation that the resident's BP had been assessed. Documentation included that the resident refused breakfast, drank 120 ml. Refused all food and fluids for lunch, ate 25% of evening meal and drank 240 ml. Accepted all supplements. Refused some evening and bed time medications. ~ 1/6/19, No night shift entry. The medical record did not include documentation that staff completed a hydration assessment for R1 and did not complete a 24 hour fluid intake calculation. ~ 1/7/19, Day shift. Refused AM medications stated, don't feel well. Vital signs of afebrile, pulse 60, (no BP recorded). ~ 1/7/19, PM shift. Afebrile, pulse 85, BP 122/75. Refused supplements and medications stating, can't keep anything down. Given medication for nausea. Medication effective. PM intake 480 ml. Incontinent x 1. Tolerating water. No emesis. The resident had refused 6 of 7 supplements for the day. The resident had refused all three meals and all fluids served with meals. ~ 1/7/19, No night shift entry. The medical record did not include documentation that staff completed a hydration assessment for R1 and did not complete a 24 hour fluid intake calculation. R1 had refused all medications on 1/7/19. On 1/7/19, R1's family member contacted a non attending physician indicating (R1) drinking very little and dehydration suspected (e.g., no urine >12 hours, very dry mouth, very light headed). The triage nurse instructed the resident's family member to send the resident to the emergency room , but the resident refused. This correspondence was given to the Surveyor by DON (Director of Nursing)-A and stated, I just found this in (R1's) chart. I didn't know it was there. ~ 1/8/19 at 1:14 AM, Resident remains on contact precautions for noted loose stools and emesis over previous 24-28 hours. No emesis noted this night. Reported nausea to be much improved. Remains afebrile. Has been able to tolerate water this night without difficulty. Will continue to observe as needed. ~ 1/8/19, Intake PM. 480 ml. Incontinent x 1. Intake for past 24 hours is 600 ml. BP 122/75. Intake for nights 120 ml. Incontinent x 2. Refused medications. Day intake 360 ml Incontinent x 1. Afebrile, pulse 64, BP 110/71. No loose stools on nights. The resident had eaten 50% of breakfast and taken in 240 ml of fluids during the breakfast meal and refused both lunch and supper meals and fluids served with meals. The resident refused all dietary fluid nutritional supplements on 1/8/19 and had refused all medications on 1/8/19. The medical record did not include documentation that staff completed a hydration assessment for R1 and did not complete a 24 hour fluid intake calculation after R1 continued to refuse medications, meals and oral intake on 1/8/19. ~ 1/9/18 at 11:20 AM, Had 2 loose golden stools, slightly more substance. Appetite poor today. Declined med's today, denies nausea when asked but later complained of some nausea. No emesis. More with drawn today and keeping eyes closed. ~ 1/9/19 at 4:27 PM, Had 2 more loose golden colored stools, slightly more substance. Appetite poor today. Abdomen soft with active bowel sounds, drinking water at times. Poor food intake. Lungs sound clear anteriority. Verbalizes, not feeling right but unable to explain what is feeling. Afebrile. Will have MD assess on round this evening. Will continue to observe. Intake days 480 ml. Incontinent x 3. BP 110/70. The resident had refused all supplements, 99% of medications, and had refused all three meals and fluids served with meals on 1/9/19 with the exception of taking in 240 ml at breakfast. The medical record did not include documentation that staff completed a hydration assessment for R1 and did not complete a 24 hour fluid intake calculation. On 1/9/19 at approximately 6:30 PM, R1's physician, MD (Medical Doctor)-C, made routine rounds on residents at the nursing facility and examined R1. MD-C's documentation indicated R1 had diarrhea, decreased appetite and weakness with dry oral mucosa and decreased level of alertness. MD-C indicated R1 had acute GE with acute de-conditioning, dehydration and increased tremors. MD-C sent R1 to the emergency room for evaluation. The emergency room provider report dated 1/9/19, documented R1 opens eyes to command but follows no additional commands. Laboratory findings included an increase in the resident's creatinine level to 1.28, previous level of 0.97 on 5/31/18 and a significant low potassium level of 2.3. (Potassium level of less than 2.5 is considered to be very serious and can cause abnormal heart rhythms, even when slightly low if the patient already has a heart disorder). R1 was admitted to the hospital for a 3 day stay and received IV fluids and IV potassium. The hospital history and physical dated 1/9/19, documented R1 had severe [DIAGNOSES REDACTED] (low potassium) due to gastrointestinal loss, possible [MEDICAL CONDITION] gastroenteritis and dehydration. The document indicated, Resident has a significant electrolyte imbalance with a potassium of only 2.3. This is most likely a result of vomiting and diarrhea that are probably from an acute GE. The hospital discharge summary dated 1/12/19, documented The patient (R1) was notably more alert and active thought to be at baseline prior to discharge. R1's stool culture results were positive for Norovirus. On 1/22/19 at 11:40 AM, the Surveyor interviewed DM (Dietary Manager)-D regarding R1. DM-D stated, I can't recall specifically of (R1's) fluid needs or if I was aware, had been notified of the resident not eating or drinking. I did make a note after (R1) went to the hospital. Review of the DM note dated 1/9/19 at 4:46 PM, indicated, Per stand up per nursing, elder is on GI precautions at this time. Observing. On 1/22/19 at 12:00 PM, the Surveyor interviewed DON (Director of Nursing)-A regarding R1. DON-A verified staff were to complete hydration assessments for residents who presented with a significant change in condition such as vomiting, nausea, diarrhea and poor oral intake of food and fluids to include vital signs, assessment of oral mucosa moistness, skin tenting and comprehensive intake and output evaluation. DON-A stated, The night nurse is to tally intake and output for the past 24 hours. We don't tell staff to complete orthostatic BP's during hydration assessments, but I know with assistance, (R1) can sit at the bedside to accomplish those. I don't see any complete hydration assessments documented for (R1). I came in later in the day on 1/9/19 and the day nurse (RN (Registered Nurse)-B) told me (R1) was asking to see the doctor. When the doctor came in for routine rounds at about 6:30 PM that evening, I asked him to see (R1) first. On 1/22/19 at 12:15 PM, the Surveyor interviewed RN-B regarding R1. RN-B stated, The doctor was making routine rounds late afternoon on 1/9/19. I told (R1) that the doctor would be here in a couple of hours. That was about 4:00 PM and the resident was asking to see the doctor. Two days prior, I was told that (R1) did not want to go to the hospital. The resident often refused lunch prior to most recent illness. A hydration assessment would include if the resident was urinating or not, skin tenting, eye balls, dry mucous membranes, a change in cognition, and vital signs and oral intake. I could look back at all the data but it is hard to get a good picture when there are several staff doing data collection. I didn't chart anything related to a specific hydration assessment for (R1) on 1/9/19 since I knew the doctor was coming in later in the day. I did look at (R1) on 1/9/19. R1 was a little more weak and more needy and calling out a lot. I did not look back the previous days to see what was going on with (R1). We get report from the previous shift but with 40 residents to look after, it's hard to keep track of everyone.